i 


GYNECOLOGICAL  OPERATIONS 


HARTMANN 


Gynecological  Operations 


INCLUDING 


Non-operative  Treatment  and 
Minor  Gynecology 


BY 

HENRI   HARTMANN 

PROFESSOR  OF  THE  FACULTY  OF  MEDICINE,  PARIS;  SURGEON  TO  THE  LABNNEC  HOSPITAL,  PARIS; 
MEMBER  OF  THE  SOCIETY    OF   OBSTETRICS  AND   GYNECOLOGY;   MEMBER  OF  THE  SOCIETY  OF 
SURGERY;  MEMBER  OF  THE  INTERNATIONAL   SOCIETY  OP  SURGERY;  FORMER  PRESI- 
DENT OF  THE   FRENCH  CONGRESS  OF  GYNECOLOGY;   HONORARY  FELLOW,  CLIN- 
ICAL SOCIETY  OF  LONDON;   HONORARY  FELLOW,  ROYAL  COLLEGE  OF 
SURGEONS,  IRELAND;  sc.  D.,  TRINITY  COLLEGE,  ETC. 


AUTHORIZED   TRANSLATION    UNDER   THE    AUTHOR  S    SUPERVISION 

BY 

DOUGLAS  W.  SIBBALD,  M.  B.,  Ch.B.  Edin. 

FORMERLY   PHYSICIAN   TO   THE   BRITISH    HOSPITAL,    LEVALLOIS-PERRET,    PARIS. 


WITH  422  ILLUSTRATIONS 
A  NUMBER  OF  WHICH  ARE  IN  COLORS 


P.   BLAKISTON'S   SON   &   CO. 


I 

,,., 


COPYRIGHT,  1913,  BY  P.  BLAKISTON'S  SON  &  Co. 


THE.  MAP 


LE-PRESS.  YORK.  PA 


r  / 


AUTHOR'S  PREFACE  TO  THE  TRANSLATION 


In  the  work  we  are  now  publishing  we  have  endeavored  to 
give  as  complete  an  exposition  as  possible  of  the  diverse  methods 
of  treatment  employed  in  gynecology.  Although  operative 
technic  occupies  pride  of  place,  nevertheless  non-operative 
treatment  is  also  fully  considered  as  there  is  a  general  return 
to-day  toward  this  branch  of  therapeutics.  For  this  reason  we 
have  considered  it  necessary  to  devote  a  place  to  minor  gyne- 
cology, mineral  water  cures,  kinestherapy,  and  electrotherapy. 
We  have  given  special  attention  to  procedures  of  choice  and  to 
the  large  number  of  our  figures  and  diagrams,  in  endeavoring 
to  illustrate  each  stage  of  an  operation,  whilst  we  have  entered 
freely  into  operative  procedures  and  the  details  of  ante-  and  post- 
operative treatment. 

We  have  briefly  described  the  procedures  of  other  gyne- 
cologists and  the  numerous  references  will  enable  the  reader  to 
secure  the  original  texts. 

With  regard  to  the  results  or  indications  of  the  operations, 
we  have  always  endeavored  to  consider  their  bearing  on  future 
pregnancies  or  the  effect  of  pregnancies  on  the  operations. 
We  are  of  opinion  that  the  work  will  be  of  value  to  all  those 
who  have  to  treat  gynecological  cases. 

HENRI  HARTMANN. 


"TRANSLATOR'S  PREFACE' 


The  fact  that  Professor  Hartmann's  "Gynecologic  Ope'ratoire" 
has  Diet  with  so  much  success  since  its  appearance,  shows  that 
in  some  special  way  it  has  met  the  wants  of  gynecologists  and 
students  in  France.  The  characteristics  which  have  thus  com- 
mended the  work  are  its  eminent  practicality  and  its  conscien- 
tious exploitation  of  a  domain  of  operative  surgery  hitherto 
imperfectly  dealt  with  in  this  country. 

In  the  task  of  translating  I  have  endeavored  to  convey  the 
author's  meaning  accurately  by  a  rigid  adherence  to  the  original 
text. 

In  conclusion  I  beg  to  thank  Professor  Hartmann,  to  whom 
I  submitted  the  translation  during  its  growth,  for  his  help  and 
unfailing  courtesy. 

DOUGLAS  W.  SIBBALD. 

British  Hospital,  Paris. 


Vll 


TABLE  OF  CONTENTS. 


PART  I. 

MEANS  OF  DIAGNOSIS  AND  OP  TREATMENT  EMPLOYED  IN  GYNECOLOGY 
CHAPTER  I. — THE  CLINICAL  EXAMINATION  IN  GYNECOLOGY. 

PAGE 

SUMMARY:  INTERROGATION — PHYSICAL  EXAMINATION:  FIRST,  OF  THE  ABDOMEN; 
SECOND,  OF  THE  VAGINA;  THIRD,  EXAMINATION  AFTER  ANESTHESIA  IN  THE  LEFT 
LATERAL  POSITION,  IN  THE  STANDING  POSITION,  IN  THE  GENUPECTORAL 

POSITION;  HYSTEROSCOPY 1 

Interrogation 2 

Menstruation 2 

Vaginal  discharges 4 

Swellings 4 

Pains 4 

Extrauterine  symptoms 5 

Ovarian  insufficiency 6 

Physical  examination 6 

Examination  of  the  abdomen 7 

Inspection 7 

Percussion 7 

Palpation 7 

Auscultation 9 

Method  of  genital  examination 9 

Inspection      9 

Vaginal  examination 10 

Bimanual  examination 11 

Rectal  examination 15 

Examination  with  the  speculum 15 

Appendix 18 

Anesthesia 18 

Left  lateral  position 19  . 

Standing  position 19 

Knee-chest  position      20 

Hysteroscopy 20 

CHAPTER  II.— MINOR  GYNECOLOGY. 

SUMMARY:  VAGINAL  INJECTIONS — VAGINAL  MEDICATION — To  TAMPON  THE  VAGINA 
— CATHETERIZATION  OF  THE  UTERUS — DILATATION  OF  THE  UTERUS:  FIRST, 
RAPIDLY;  SECOND,  SLOWLY — INTRAUTERINE  MEDICATION  (LAVAGES,  INJEC- 
TIONS, LOCAL  APPLICATIONS  AND  CAUSTICS) DRAINAGE  OF  THE  UTERUS 

ATMOKAUSIS — ZESTOKAUSIS — BIER'S  METHOD — PESSARIES — CURETTING  THE 

UTERUS 22 

Vaginal  injections 22 

Instruments 22 

Technic  of  vaginal  irrigation 24 

Indications  and  contraindications  to  vaginal  irrigation      26 

ix 


x  TABLE  OF  CONTENTS 

PAGE 

Vaginal  medication 27 

Tamponing  the  vagina 28 

Catheterization  of  the  uterus 29 

Technic 30 

Indications 30 

Dilatation  of  the  uterus 31 

Rapid  dilatation 31 

Technic 33 

Slow  or  gradual  dilatation 34 

Instruments  required 34 

Technic 35 

Indications 36 

Intrauterine  medication 37 

Intrauterine  lavage < 37 

Intrauterine  lavage  in  the  puerperal  state 37 

Technic 39 

Complications 42 

Indications  and  contraindications 43 

Intrauterine  injections 43 

Application  of  medicated  bougies  and  of  caustics  to  the  uterine  cavity 45 

Probes  for  applying  caustics 47 

Drainage  of  the  uterus 47 

Atmokausis 48 

Technic 50 

Complications 50 

Indications 51 

Bier's  method 52 

Pessaries 53 

Complications  to  the  use  of  pessaries 58 

Indications  for  the  use  of  pessaries 59 

Curetting  the  uterus 60 

History 60 

Technic 60 

Anesthesia  in 61 

Operation  in 61 

Complications 65 

Indications  for  .  68 


CHAPTER  III. — PHYSICAL  AGENTS  IN  GYNECOLOGY. 

SUMMARY:  ELECTROTHERAPY  (INSTRUMENTS,  PHYSIOLOGICAL  BASES,  INDICATIONS) — 

KlNETOTHERAPY HYDROTHERAPY MINERAL  WATERS      73 

Electrotherapy 73 

Instruments 73 

Physiological  bases 73 

Indications 81 

Organic  lesions 82 

Kinetotherapy 88 

Massage 89 

Movements 90 

Sismotherapy 93 

Hydrotherapy 93 

Hydromineral  treatment 94 


TABLE  OF  CONTENTS  xi 

PART  II. 
TECHNIC'OF  OPERATIONS  ON  THE  VULVA,  VAGINA,  UTERUS  AND  ADNEXA. 

CHAPTER  I. — SURGERY  OF  THE  VULVA. 

PAGE 

SUMMARY:  ANATOMICAL  ELEMENTS — TREATMENT  OP  TRAUMATIC  LESIONS  (WOUNDS 
AND  CONTUSIONS) — TREATMENT  OF  INFLAMMATORY  LESIONS  (SUPERFICIAL 
AND  DEEP) — KRAUROSIS — LEUCOPLASIA  AND  PRURITUS  VULV^E — OPERATION 
ON  THE  VULVA  DIMINISHING  IT  (iNFIBRILATION,  EPISIORRHAPHY,  NYMPHOR- 
RHAPHY) — VULVO-VAGINAL  CONSTRICTION — RADICAL  OPERATION — EXCISION 
OF  THE  CLITORIS,  OF  INFLAMMATORY  LESIONS  AND  OF  TUMORS  (BENIGN  AND 

MALIGNANT) — TREATMENT  OF  VAGINISMUS 98 

Elements  of  anatomy 98 

Treatment  of  wounds  of  the  vulva 101 

Treatment  of  contusions  of  the  vulva 101 

Treatment  of  inflammatory  lesions    .    .    .    .  ' - 102 

Treatment  of  deep  inflammatory  lesions  .    .    .    .  .  k 104 

Treatment  of  kraurosis  and  leucoplasia 105 

Treatment  of  vulvar  pruritus      105 

Operations  on  the  vulva      106 

Operations  constricting  or  closing  the  vulva 107 

Operations  enlarging  the  vulvar  orifice 107 

Treatment  of  cicatricial  constriction  ....*.. 108 

Operations  for  excision 110 

Removal  of  the  clitoris 110 

Excision  of  inflammatory  lesions Ill 

Extirpation  of  vulvar  neoplasms 112 

Treatment  of  benign  tumors 112 

Treatment  of  malignant  tumors 114 

Treatment  of  vaginismus 115 

Brusque  dilatation  under  anesthesia 116 

Excision  of  the  hymen  and  of  the  vaginal  entrance *  ....    116 

Plastic  operations 116 

Resection  of  the  internal  pudic  nerve 117 


CHAPTER  II. — SURGERY  OF  THE  VAGINA. 

SUMMARY:  TREATMENT  OF  TRAUMATIC  LESIONS  (WOUNDS,  HEMATOMAS,  FOREIGN 
BODIES) — TREATMENT  OF  INFLAMMATORY  LESIONS — TREATMENT  OF  TUMORS 
(BENIGN  AND  MALIGNANT) — TREATMENT  OF  STRICTURES  AND  ATRESIA  OF  THE 

VAGINA;  FORMATION  OF  NEO-VAGINAS 119 

Treatment  of  traumatic  lesions  (wounds) 119 

Treatment  of  hematomas 120 

Treatment  of  foreign  bodies 120 

Treatment  of  inflammatory  lesions 121 

Treatment  of  vaginitis • 121 

Treatment  of  tumors 123 

Treatment  of  stricture  and  atresia  of  the  vagina 125 

Strictures  of  the  vagina 126 

Vaginal  atresia      127 

Formation  of  a  neo-vagina 129 


xii  TABLE  OF  CONTENTS 

CHAPTER  III. — PLASTIC  OPERATIONS  ON  THE  PERINEUM  AND  VAGINA. 

PAGB 
SUMMARY:  GENERAL  TECHNIC  OP  PLASTIC  OPERATIONS — TREATMENT  OF  PERINEAL 

TEARS,    COLPOPERINEORRHAPHY ANTERIOR     COLPORRHAPHY NARROWING 

OF   THE   VAGINA   BY   INTRODUCING  METALLIC  SUTURES — PARTITIONING  OF 

THE  VAGINA,  CoLPECTOMY TREATMENT  OF  RECTO-VAGINAL  FISTULA    .    .    .  136 

General  technic  of  plastic  operations 136 

Treatment?  of  perineal  tears 138 

Preventative  treatment 138 

Curative  treatment 139 

Immediate  perineorrhaphy 138 

Secondary  perineorrhaphy 141 

Late  perineorrhaphy 141 

Colpoperineorrhaphy 142 

Colpoperineorrhaphy  by  resection 142 

Veit's  procedure 148 

Old  and  complete  tears  of  the  perineum 148 

Old  tears  complicated  by  prolapse 149 

Hegar's  procedure 150 

Colpoperineorrhaphy  by  division  and  splitting 151 

Incomplete  perineal  tears 151 

Complete  tear  of  the  perineum 156 

Old  tears  complicated  by  prolapse 158 

Anterior  colporrhaphy      162 

Extensive  anterior  colporrhaphy  for  colpocystocele 163 

Various  procedures 166 

Constriction  of  the  vagina  by  metallic  sutures 168 

Colpectomy 169 

Treatment  of  recto-vaginal  fistulas 171 

Operation  by  the  recto-vaginal  route 171 

Operation  by  the  vaginal  route 174 

Operation  by  perineal  route 174 

Operation  by  the  vagino-perineal  route 176 

CHAPTER  IV. — OPERATIONS  ON  THE  CERVIX  UTERI. 

SUMMARY:  TEMPORARY  OR  DEFINITE  OCCLUSION  OF  THE  CERVIX — TEMPORARY  OR 

DEFINITE   TRACHELOTOMY,  COUTY'S  AND  PoZZl'S  OPERATION TRACHELOR- 

RHAPHY  BY  DENUDATION  OR  FLAPS AMPUTATION  OF  THE  CERVIX,  INFRA- 
VAGINAL  OR  SUPRA  VAGINAL VARIOUS  OPERATIONS BoUILLY's  AND  PoUEY's 

OPERATION — OPERATIONS    FOR    UTERINE    FLEXIONS — OPERATION    ON    THE 

CERVIX  AND  PREGNANCY 177 

Occlusion  of  the  cervix 177 

Trachelotomy 178 

Pozzi's  operation 181 

Trachelorrhaphy 182 

Trachelorrhaphy  with  surface  denudation 183 

Trachelorrhaphy  with  flaps     .    .  • 184 

Amputation  of  the  cervix 184 

Two-flap  amputation ' 185 

One-flap  amputation '. 186 

Supravaginal  amputation 189 

Amputation  with  the  knife 190 


TABLE  OF  CONTENTS  xiii 

PAGB 

Amputation  with  galvanocautery 190 

Various  operations 192 

Scarification  of  the  cervix 192 

Bouilly's  operation 192 

Pouey's  operation 192 

Operations  for  uterine  flexion 193 

Operations  on  the  cervix  and  pregnancy 195 

t 

CHAPTER  V. — LIGATURE  OF  THE  UTERINE  ARTERIES  BY  THE  VAGINAL  ROUTE. 

SUMMARY:  GENERAL  ANATOMY — OPERATIVE  TECHNIC — INDICATIONS 198 

Operative  technic 200 

Indications 201 

CHAPTER  VI. — REMOVAL  OF  FIBROMATA  BY  THE  VAGINAL  ROUTE. 

SUMMARY:  REMOVAL  OF  FIBROUS  POLYPI  AND  FIBROMATA  OF  THE  CERVIX — TRANS- 

VAGINO-UTERINE  MYOMECTOMY TRANSVAGINAL  MYOMECTOMY 202 

Removal  of  fibrous  polypi 202 

Removal  of  cervical  fibromata 203 

Transvagino-uterine  myomectomy 204 

Transvaginal  myomectomy 212 

CHAPTER  VII.— COLPOTOMIES. 

SUMMARY:  POSTERIOR  COLPOTOMY — ANTERIOR  COLPOTOMY     ..........  213 

Posterior  colpotomy      213 

Fixing  of  the  uterus  in  the  vagina  with  the  fundus  below  or  "  Bascule"  of  the  uterus  217 

Anterior  colpotomy 219 

CHAPTER  VIII. 

SUMMARY:   TECHNIC — OPERATIVE   DIFFICULTIES — COMPLICATIONS — VARIOUS    PRO- 
CEDURES— OPERATIVE  MODIFICATIONS  ACCORDING  TO  THE  LESION     ....  235 

Operative  technic 236 

Operative  difficulties 251 

Complications 252 

Operative  modifications  according  to  the  nature  of  the  lesion 261 

Vaginal  hysterectomy  in  fibromata 263 

CHAPTER  IX. — HYSTERECTOMY  BY  THE  PARAVAGINAL  ROUTE. 

SUMMARY:  HISTORY — OPERATION — RESULTS 273 

History 273 

Operation 274 

Results  and  indications 281 

CHAPTER  X. — PERINEAL  AND  SACRAL  ROUTES. 

SUMMARY:  TRANSVERSE  AND  SAGITTAL  PERINEOTOMY — OPERATION  BY  THE  SACRAL 

ROUTE — PARASACRAL  INCISION — RESECTION  OF  THE  RECTUM 282 

Perineotomy 282 


xiv  TABLE  OF  CONTENTS 

PAGE 

Transverse  perineotomy 282 

Sagittal  perineotomy 283 

Parasacral  route  .    283 


PART  III. 

OPERATIONS  BY  THE  ABDOMINAL  ROUTE. 

CHAPTER  I. — SHORTENING  OF  THE  ROUND  LIGAMENTS  IN  THE 
INGUINAL  REGION. 

SUMMARY:  ANATOMICAL  SURVEY — OPERATIVE  TECHNIC — RESULTS — INDICATIONS  .   286 

Anatomical  recapitulation 286 

Operative  technic 287 

Results  and  indications 291 

CHAPTER  II. — ABDOMINAL  CELIOTOMY. 

SUMMARY:    GENERAL   TECHNIC — OPERATIVE  PRECAUTIONS — MEDIAN  CELIOTOMY — 

TRANSVERSE  CELIOTOMY — POSTOPERATIVE  PRECAUTIONS — COMPLICATIONS  .   293 

General  technic  of  abdominal  celiotomy 293 

Preparatory  measures 296 

Operation .    .    . N 299 

Median  celiotomy 299 

Abdominal  incision 301 

Transverse  celiotomy 320 

Complications  of  celiotomy 323 

CHAPTER  III. — ABDOMINAL  HYSTERECTOMY. 

SUMMARY:    ABDOMINAL    HYSTERECTOMY — TYPES    OF    PROCEDURE,    VARIOUS    PRO- 
CEDURES— INDICATIONS  AND  MODIFICATIONS  OF  TECHNIC  ACCORDING  TO  THE 

NATURE  OF  THE  LESION       239 

Types  of  procedure 329 

Various  procedures 338 

Hysterectomy  by  primary  excision  of  the  uterus 341 

Hysterectomy  by  continuous  transverse  section 341 

Hysterectomy  by  uterine  hemisection 343 

Total  hysterectomy  by  subperitoneal  decortication  with  primary  opening  of  the 

posterior  fornix  and  with  preliminary  hemostasis 345 

Indications  for  abdominal  hysterectomy,  modifications  of  technic  according  to  the 

nature  of  the  lesion  .  .347 


CHAPTER  IV. — OPERATIONS  ON  THE  TUBES  AND  OVARIES. 

SUMMARY:  REMOVAL  OF  THE  ADNEXA — CONSERVATIVE  OPERATIONS  ON  THE  TUBES 

AND  OVARIES 378 

Removal  of  the  adnexa 378 

Conservative  operation  on  the  ovary 389 


TABLE  OF  CONTENTS  xv 

CHAPTER  V. — ABDOMINAL  OPERATIONS  FOR  DISPLACEMENTS  AND  DEVIATIONS  OF  THE 

UTERUS. 

PAGE 
SUMMARY:  ANTERIOR  ABDOMINAL  HYSTEROPEXY — INDIRECT  HYSTEROPEXY — INTRA- 

ABDOMINAL  SHORTENING  OF  THE  ROUND  LIGAMENTS CuNEOHYSTERECTOMY — 

INTRAABDOMINAL  SHORTENING  OF  THE  UTEROSACRAL  LIGAMENTS 393 

Anterior  abdominal  hysteropexy 393 

Indirect  hysteropexy 398 

Intraabdominal  shortening  of  the  round  ligaments 400 

Cuneohysterectomy 404 

Intraabdominal  shortening  of  the  uterosacral  ligaments    .    .' 406 

CHAPTER  VI. — SOME  RARE  ABDOMINAL  OPERATIONS. 

SUMMARY:  OBLITERATION  OF  THE  POUCH  OF  DOUGLAS — LIGATURE  OF  THE  UTERINE 
ARTERY — LIGATURE  OF  THE  HYPOGASTRIC  VEINS — REDUCTION  OF  UTERINE 

INVERSION — CYSTOPEXY 407 

Obliteration  of  the  pouch  of  Douglas 407 

Ligature  of  the  uterine  artery  by  the  abdominal  route      409 

Ligature  of  the  hypogastric  veins 411 

Reduction  of  uterine  inversion  by  the  abdominal  route 412 

Abdominal  cystopexy 412 

PART  IV. 

THE    THERAPEUTIC    INDICATIONS    IN    DISEASES    OF    THE    GENITAL    SYSTEM    OF    WOMAN. 

CHAPTER  I. — TREATMENT  OF  INFLAMMATORY  LESIONS  OF  THE  UTERUS  AND  ADNEXA. 

SUMMARY:  METRITIS — EVOLUTION  OF  PATHOGENIC  CONCEPTION  AND  TREATMENT — 
PROPHYLACTIC  TREATMENT — CURATIVE  TREATMENT  OF  ACUTE  AND  CHRONIC 
METRITIS — INDICATIONS  FOR  TREATMENT  OF  ACUTE  AND  CHRONIC  INFLAM- 
MATION   OF   THE    ADNEXA ' 413 

Treatment  of  metritis 413 

Treatment  of  inflammation  of  the  adnexa    ........ 422 

CHAPTER  II. — TREATMENT  OF  NEOPLASMS  OF  THE  UTERUS  AND  ADNEXA. 

SUMMARY:  UTERINE  FIBROMATA — FIBROMATA  AND  PREGNANCY — MALIGNANT  TU- 
MORS OF  THE  UTERUS CANCER  OF  THE  CERVIX  AND  PREGNANCY — 

TUMORS    OF    THE   OVARY 429 

Treatment  of  uterine  fibromata , 429 

Fibroids  and  pregnancy 434 

Malignant  tumors  of  the  uterus 436 

Uterine  cancer  and  pregnancy 440 

Tumors  of  the  ovary 442 

Tumors  of  the  ovary  and  pregnancy 443 

CHAPTER  III. — DISPLACEMENTS  OF  THE  UTERUS. 

SUMMARY:  TREATMENT  OF  GENITAL  PROLAPSE — MEANS  OF  FIXATION  OF  THE  UTERUS 
ANATOMO-PATHOLOGICAL  LESIONS  OF  PROLAPSE — PROPHYLACTIC  TREATMENT 
— MEDICAL  TREATMENT — OPERATIVE  TREATMENT — TREATMENT  OF  VAGINAL 
ENTEROCELE TREATMENT  OF  UTERINE  DEVIATIONS UTERINE  INVERSIONS  .  444 

Treatment  of  genital  prolapse 444 


xvi  TABLE  OF  CONTENTS 

PAGE 

Prophylactic  and  medical  treatment 448 

Operative  treatment 449 

Treatment  of  vaginal  enterocele 457 

Treatment  of  uterine  deviations 457 

Puerperal  inversion 457 

Polypoid  inversion 458 

CHAPTER  IV. — EXTRA  UTERINE  PREGNANCY. 

SUMMARY:  GENERAL  INDICATIONS  FOR  TREATMENT  OP  EXTRAUTERINE  PREGNANCY — 
TREATMENT  OF  PREGNANCY  DURING  FIRST  FIVE  MONTHS  IN  THE  ABSENCE  OF 

COMPLICATIONS TREATMENT  OF  PERITONEAL    HEMORRHAGE   OF  ENCYSTED 

HEMATORRHEA  EITHER  INTRA-  OR  SUBPERITONEAL TREATMENT  OF  PREG- 
NANCY AFTER  FIFTH  MONTH OLD  FETAL  CYSTS 460 

Pregnancies  observed  in  the  course  of  first  five  months 461 

Pregnancy  after  the  fifth  month 462 

CHAPTER  V. — MENSTRUAL  TROUBLES  AND  STERILITY. 

SUMMARY:  MENSTRUAL  TROUBLES — PRIMARY  OR  SECONDARY  AMENORRHEA — MEN- 
ORRHAGIA — METRORRHAGIA — DYSMENORRHEA — TROUBLES  OF  THE  MENO- 
PAUSE— TREATMENT  OF  STERILITY 465 

Troubles  of  menstruation 465 

Amenorrhea 465 

Menorrhagia  and  Metrorrhagia 466 

Dysmenorrhea 467 

Troubles  of  the  menopause , 468 

Sterility 469 

PART  V. 

CHAPTER  I. — OPERATIONS  ON  THE  URINARY  APPARATUS. 

SUMMARY:  INTERROGATION — EXAMINATION  OF  URINE — EXAMINATION  OF  THE 
URETHRA — EXAMINATION  OF  THE  BLADDER — EXAMINATION  OF  THE  URETERS — 
EXAMINATION  OF  THE  KIDNEYS — INTRAVESICAL  SEPARATION  OF  THE  URINE — • 

CATHETERIZATION  OF  THE  URETERS 471 

Interrogation 471 

Examination  of  the  urine 472 

Examination  of  the  urethra 472 

Examination  of  the  bladder 475 

Examination  of  the  ureters 478 

Examination  of  the  kidneys 479 

Catheterization  of  the  ureters 479 

CHAPTER  II. — SURGERY  OF  THE  URETHRA. 

SUMMARY:    OPERATIONS    ON    THE    URETHRA — TREATMENT    OF    DISEASES    OF   THE 

URETHRA 481 

Operations  on  the  urethra 481 

Catheterization,  etc 481 

Treatment  of  diseases  of  the  urethra  .   487 


TABLE  OF  CONTENTS  xvii 

CHAPTER  III. — SURGERY  OP  THE  BLADDER. 

PAGE 
SUMMARY:    OPERATIONS    ON    THE    BLADDER — TREATMENT    OF    DISEASES    OF    THE 

BLADDER 491 

Operations  on  the  bladder 491 

Treatment  of  diseases  of  the  bladder 495 

CHAPTER  IV. — TREATMENT  OF  URINARY  FISTULAS. 

SUMMARY:  VESICOVAGINAL  FISTULAS — PROPHYLACTIC  TREATMENT— PREPARATORY 
TREATMENT OPERATIVE  TREATMENT GENERAL  TECHNIC SlMPLE  DENUDA- 
TION— TREATMENT  OF  FISTULAS  SITUATED  OPPOSITE  THE  CERVIX  UTERI — 
OPERATION  IN  SEVERAL  STAGES — SPECIAL  PROCEDURES  APPLICABLE  TO 

LARGE  LOSSES  OF  TISSUE UTEROVESICAL  FISTULAS UTEROVAGINAL  FISTULAS 

AND  DESTRUCTION  OF  THE  URETHRA FlSTULA  OF  THE  URETHRA,  ETC 498 

Vesicovaginal  fistulas 498 

Prophylactic  treatment 499 

Preoperative  and  operative  treatment 500 

Treatment  of  fistulas  situated  in  the  neighborhood  of  the  cervix  uteri 509 

Special  procedures  applicable  to  large  losses  of  substance 511 

Vesico-uterine  fistulas 514 

Uterovaginal  fistulas  with  destruction  of  the  urethra 515 

Fistulas  of  the  ureter 518 

Nephrectomy 523 

INDEX  .    525 


PART  I. 

MEANS  OF  DIAGNOSIS  AND  OF  TREATMENT 
EMPLOYED  IN  GYNECOLOGY. 

CHAPTER  I. 

THE  CLINICAL  EXAMINATION  IN  GYNECOLOGY. 

Summary:  Interrogation. — Physical  examination  first  of  the  abdomen; 
second  of  the  vagina;  third,  examination  after  anesthesia  in  the  left  lateral 
position,  in  the  standing  position,  in  the  genu-pectoral  position;  hysteroscopy. 

Before  proceeding  to  the  direct  examination  of  the  affected 
parts,  we  should  allow  the  patient  to  state  the  reasons  of  her 
visit.  While  doing  this  we  have  an  opportunity  of  observing 
her  and  of  forming  certain  impressions  of  her  general  state,  of 
her  condition  of  embonpoint  or  emaciation,  and  of  the  color  of 
her  skin  and  her  mucous  membranes.  We  are  thus  able  to  rec- 
ognise in  a  greenish-yellow  complexion,  the  subjects  of  chlorosis 
and  amenorrhea;  in  the  extreme  pallor  of  others,  victims  of 
menorrhagia ;  a  tired,  pale,  dull  and  almost  earthy  aspect  suggests 
leucorrhea,  "uterine  facies";  in  the  yellow  straw-colored  com- 
plexion we  recognize  the  subjects  of  cancer;  the  emaciated 
ovarian  facies  denotes  cysts,  and  contrasts  with  the  volume  of 
the  abdomen;  finally  a  dull  leaden-colored  face  suggests  a  con- 
dition of  septicemia. 

However,  we  should  not  wait  too  long  listening  to  these 
preliminary  examinations  which  are  usually  very  long,  rather 
confused,  and  w^hich  often  enter  fully  into  unnecessary  details 
while  neglecting  points  of  capital  importance;  and  thus  give  an 
idea  of  the  general  course  of  the  disease  and  of  the  general 
condition  of  the  patient,  but  do  not  generally  lead  to  a  diagnosis. 

Therefore  we  should  proceed  to  a  rapid  and  methodical 
interrogation  and  not  allow  the  patient  to  wander  into  uninter- 
esting digressions. 

i 


2  THE   CLINICAL   EXAMINATION   IN   GYNECOLOGY 

1.  Interrogation. 

There  is  an  advantage  in  conducting  one's  interrogation  in  a 
set  order: 

(1)  Menstruation. — The  primary  questions  should  concern 
menstruation. 

Some  patients  come  to  consult  us  for  absence  of  menstruation 
or  amenorrhea.  In  a  young  girl  who  has  gone  beyond  the  average 
age  of  menstruation,  we  must  not  necessarily  conclude  that  we 
have  to  deal  with  a  local  affection.  In  chlorotic  and  lymphatic 
patients  menstruation  appears  late ;  some  months  of  patience  and 
appropriate  treatment  wrill  decide  the  question  at  issue.  If  the 
amenorrhea  persists  we  must  think  of  a  local  affection  such  as 
absence  of  ovaries,  or  uterus,  or  a  genital  imperf oration.  In  the 
last  named,  at  a  given  moment  the  whole  of  the  menstrual 
molimen  may  come  on  (colic,  pain  in  the  kidneys,  abdominal 
bearing  down).  At  a  more  advanced  stage,  if  the  menstruation 
has  previously  commenced  normally,  amenorrhea  may  be  symp- 
tomatic, of  a  grave  general  state  or  a  cachexia  (acute  febrile 
affections,  albuminuria,  diabetes,  tuberculosis,  etc.) ;  it  may  be 
due  to  a  nervous  cause  and  this  is  quite  often  observed  immedi- 
ately after  marriage,  or  at  a  more  advanced  age,  accompanied 
then  by  tympanites  or  abdominal  polysarcia  which  may  suggest 
to  the  doctor  a  pregnancy  and  may  compromise  his  reputation. 
This  is  a  condition  of  spurious  pregnancy  dependent  on  a  nervous 
origin. 

It  is  important  to  fix  the  date  of  the  last  menstruation.  The 
mind  of  the  gynecologist  should  be  haunted  by  the  idea  of  a 
possible  pregnancy  in  the  patient  who  comes  to  consult  him. 
While  on  this  subject  remember  that  one  may  be  deceived  by 
the  ignorance  of  the  patient  and  her  wilful  deceit.  In  such  a 
case  as  the  latter  the  patient  wishes  an  examination  to  procure 
an  abortion  sequence. 

We  should  not  only  determine  the  date  of  the  last  menstrua- 
tion, but  the  dates  of  the  two  last  so  as  to  be  able  to  determine  the 
non-interruption  of  the  function.  What  the  patient  calls  her  last 
menstruation  may  in  reality  only  be  a  symptomatic  metrorrhagia 
of  an  abortion  already  passed  or  threatening.  By  finding  out 
about  the  last  two  menstruations  we  avoid  this  pitfall. 


INTERROGATION  3 

Having  cleared  up  this  point,  we  should  study  the  menstru- 
ation at   all  .epochs  during  the    patient's  life.     When   did  the 
first    menstruation    occur  ?      Did    it    come    without   difficulty 
and  without  pain  ?     How  has  menstruation  progressed  since  ? 
Does    the    patient    suffer    during    menstruation  ?     And    if    she 
suffers,    do   the   pains   come   on    before   menstruation   occurs  ? 
If  the  answer  is  yes,  then  we  should  suspect  a  probable  ovarian 
lesion.     Again,  if  the  patient  suffers,  does  she  do  so  when  the 
menstrual   flow   is   established.     In   such   a   case   we   think   of 
some  obstruction  to  the  flow  of  blood  from  the  utdlois;  stenosis 
of  the   cervix,  either  congenital  or  acquired;  uterine  deviation, 
most  often  an  anteflexion.     If  in  the  latter  case,  the  patient 
describes   that   after   an   accouchement   she   has   remained   six 
months,  a  year,   or  two  years  without  suffering  the  existence 
of  a  mechanical  obstacle  to  the  escape  of  the  blood,  more  particu- 
larly an  anteflexion  of  the  uterus  is  almost  certain.     After  the 
enquiry    into    the    painful    symptoms    which    may    precede    or 
accompany  the  menstrual  periods,   it  is  necessary  to  enquire 
as  to  their  quantity  and  duration.     As  this  quantity  and  duration 
varies  in  different  women  it  is  well  to  ask  not  only  what  actually 
comes  away  but  also  what  the  habit  was  formerly  and  to  com- 
pare the  two.     It  is  thus  easy  to  appreciate  if  there  is  really  an 
exaggeration    of    the    menstrual    outflow,    that   is,    if   there   is 
menorrhagia.     Other  important  questions  to  be  asked  are :     Does 
the  patient  lose  blood  in  the  intervals  of  the  menstrual  epochs, 
so-called    " metrorrhagia" ?     Are    the    losses    slight  and  inter- 
mittent ?     Is  it  a  question  of  a  simple  oozing  of  blood,  or  is 
the  flow  considerable  and  continuous  ?     The  replies  to  these  are 
sometimes  exaggerated,  so  it  is  best  to  determine  approximately 
the  amount  of  blood  lost  by  asking  the  number  of  diapers  soiled 
during  the  day. 

The  study  of  the  losses  of  blood  is  completed  by  enquiry  into 
the  character  of  the  hemorrhagic  outflow. 

Does  the  woman  lose  fluid  blood,  or  does  it  come  away  in 
clots  ?  Is  the  loss  accompanied  by  the  expulsion  of  membranes, 
of  "skin"  as  the  patients  say,  or  even  of  fetal  remnants?  All 
these  questions  are  important ;  they  often  allow  of  diagnosis  being 
made  even  before  local  examination:  for  example,  abortion 
(woman  young,  loss  with  clots  after  an  interval) ,  mural  fibroma, 


4  THE    CLINICAL   EXAMINATION   IN   GYNECOLOGY 

menorrhagia  in  a  woman  somewhat  older),  or  polypi  (con- 
tinuous metrorrhagia) ,  cancer  (a  woman  after  the  menopause 
having  a  hemorrhagic  outflow,  etc.). 

(2)  Vaginal    Discharges. — Does    the    patient    complain    of 
"whites"?     And  if  these  exist,  is  it  a  question  of  a  recent  dis- 
charge or  does  it  date  back  some  months  ?     Has  it  come  on 
apparently  without  cause,  or  can  the  patient  herself  give  it  an 
etiology  connecting  it  with  some  definite  event  in  her  genital 
life,  abortion,  accouchement,  etc.  ?     What  are  the  characters  of 
it  ?     Is    the  discharge    thick,   ropy,   viscous,    odorless    (cervical 
catarrh)  ?     Is  it  purulent  with  an  acid  smell  (simple  vaginitis, 
the  white  discharge  in  anemic  patients),  or  is  it  serous,  some- 
times lightly  tinted,  of  a  putrid  odor  (cancer)  ? 

(3)  Swellings. — Is  the  patient  a  virgin  in  the  true  gynecological 
sense  ?     Has  she  had  children  ?     How  many  ?     Have  they  come 
at  the  term  or  before  it  ?     What  sort  of  accouchements  has  she 
had  ?     Have  they  been  difficult  ?     Has  intervention  been  neces- 
sary ?     Has  the  perineum  been  torn  ?     Has  the  parturition  been 
regular    and    complete  ?     Has    the    puerperium    been    compli- 
cated by  accidents  (fever,  vomiting,  distention  of  the  abdomen, 
etc.)  ?     Have    there    been    abortions  ?     What   have    been    their 
results  ? 

(4)  Pains. — -Although    extremely    variable    in    its    intensity, 
pain  is  rarely  absent.1     Is  the  pain  in  the  inferior  part  of  the 
abdomen  and  is  it  median  or  lateral;  or  is  it,  on  the  contrary, 
a  question  of  lumbar  pains  or  of  pains  in  the  legs  or  a  pain  of 
coccygodynia  ?     What  are   the  characters   of  these   pains  ?     Is 
there  true  pain  or  simply  a  sensation  of  fatigue,  of  weight  or 
a  pain  of  uterine  colic,  tearing-down  pains,  which  the  patient 
who  has  'been  a  mother  compares  always  with  the  pains   of 
parturition. 

The  conditions  in  which  these  pains  occur  have  quite  a 
special  importance.  We  have  already  seen  the  significance  of 
the  pains  which  accompany  or  precede  menstruation  as  regards 
other  pains;  the  influence  of  repose  or  fatigue  on  them  should 

1  It  must  not  be  forgotten  in  the  study  of  pains  in  the  region  of  the  genital  organs 
that  hysteria  may  be  the  cause.  It  is  necessary  then  to  search  for  other  signs  (neurosis 
insomnia,  mastodynia,  intercostal  neuralgia,  etc.),  remembering  that  hysteria  and  geni- 
tal trouble  may  coexist,  the  latter  keeping  up  or  exaggerating  the  general  symptoms  of 
the  former. 


INTERROGATION  5 

be  noted.  If  the  patient  is  relieved  by  rest  in  bed  and  only 
suffers  when-  she  walks,  one  is  dealing  with  a  metritis.  If  she 
suffers  even  during  rest  in  bed  there  is  probably  a  lesion  of  the 
adnexa.  This  shows  how  important  it  is  to  determine  the 
conditions  giving  rise  to  the  symptom,  pain. 

Pruritus,  vulvar  or  anal,  constitutes  a  last  variety  of  the 
symptom,  pain;  it  may  be  due  to  exterior  cause  (eczema,  dia- 
betes, parasites),  to  the  irritant  action  of  a  leucorrheal  discharge, 
or  again  simply  to  a  nervous  cause. 

Having  thus  determined  the  different  functional  symptoms  of 
the  patient  as  regards  her  genital  organs,  it  is  necessary  to 
complete  the  examination,  to  examine  her  remaining  systems. 

(5)  Extrauterine  Symptoms. — Urinary  troubles  are  frequent; 
they  may  even  dominate  the  clinical  picture  so  markedly  as  to 
make  one  believe  it  is  an  essential  lesion  of  the  bladder  that  pre- 
sents itself  when  really  these  bladder  symptoms  result  from  a  lesion 
of  the  genital  organs.  It  suffices,  it  is  true,  to  determine  with 
care  the  character  of  the  symptoms  observed  to  connect  them 
with  their  true  cause.  If  the  pains  appear  more  especially 
when  the  patient  is  upright  and  are  more  marked  when  she  is 
•  fatigued,  and  if  the  urine  is  clear,  without  deposit,  it  is  not  a 
question  of  cystitis  but  simply  of  reflex  bladder  trouble,  arising 
from  some  genital  trouble  that  may  be  determined  by  physical 
examination.  It  must  be  noted,  however,  that  the  association 
of  vesical  and  genital  affections  is  frequent;  it  may  be  that  the 
same  agent  has  exercised  its  action  on  the  urinary  as  \vell  as  on 
the  genital  apparatus  or  possibly  resulting  from  a"genital  affec- 
tion the  bladder  has  been  infected  through  its  walls;  or  the 
bladder  may  simply  be  drawn  on  by  adhesions  following  a 
pelvic  peritonitis,  etc.  The  importance  of  rectal  symptoms  is 
not  so  great.  Constipation,  and  even  the  entero-colitis  following 
it,  is  the  habitual  companion  of  gynecological  lesions.  It  is 
often  accompanied  by  gastric  troubles  also;  in  fact,  these  are 
rarely  absent.  The  relation  between  dyspeptic  troubles  and 
lesions  of  the  genital  system  is  experenced  daily.  Vomiting  and 
migraine  are  often  enough  observed.  In  many  women  there  is 
besides  an  association  of  lesions  of  sundry  systems,  genital 
affection,  flaccidity  of  the  abdominal  wall,  enteroptosis,  etc. 

Recently  a  certain  importance  has  been  attached  to  the  re- 


6  THE   CLINICAL   EXAMINATION   IN   GYNECOLOGY 

search  of  a  train  of  symptoms  characterizing  a  faulty  in- 
ternal secretion  of  the  ovary  which  Jayle  gives  as  being  char- 
acteristic of  what  he  calls  ovarian  insufficiency.  Together  with 
menstrual  troubles,  amenorrhea  and  dysmenorrhea,  there  exist 
in  these  cases,  a  group  of  vasomotor,  nervous,  and  trophic 
symptoms,  heat  flushings,  enfeeblement  of  memory,  modifica- 
tion of  character,  signs  of  neurasthenia  and  neuro-muscular 
asthenia,  adiposity  or,  more  rarely,  emaciation. 

2.  Physical  Examination. 

It  may  seem,  at  first  sight,  to  be  useless  or  even  somewhat 
ridiculous  to  impress  the  necessity  of  this  physical  examination; 
however,  daily  examples  show  that  it  is  not  at  all  a  superfluous 
recommendation  and  that  this  elementary  precept  is  but  too 
often  forgotten. 

Its  omission  leads  to  very  gross  errors,  of  which  it  is  easy  to 
quote  a  few  examples.  A  young  girl  comes  before  us  with  an 
abdominal  tumor;  one  passes  in  review  all  possible  tumors,  preg- 
nancy excepted  ?  How  can  one  consider  the  latter  possibility  in 
a  young  girl,  carefully  brought  by  her  mother,  and  never  even 
having  menstruated  ?  Considerations  of  every  kind  tend  to  show 
the  impossibility  of  such  a  hypothesis.  Yet  on  direct  examina- 
tion, however  impossible  pregnancy  may  have  appeared,  it  is 
none  the  less  present.  Here  is  another  case :  A  young  girl  who 
has  not  yet  menstruated  suffers  from  various  strange  symptoms 
with  seemingly  no  cause  and  for  which  she  has  followed  all 
kinds  of  treatment.  Direct  examination  at  once  shows  the  exist- 
ence of  an  imperforate  hymen,  causing  a  hematocolpos,  thus 
giving  the  key  to  all  the  symptoms  observed.  There  are  examples 
even  more  curious  of  the  utility  of  this  direct  examination. 
Munde  quotes  a  case  of  twins,  each  treated  for  many  months 
for  persistent  amenorrhea;  on  making  an  examination  he  found 
that  they  were  in  reality  two  men  with  hypospadias,  whose  true 
sex  had  not  till  then  been  recognized  through  want  of  sufficient 
examination. 

There  should  be  no  hesitation  then  in  making  a  direct  exami- 
nation in  all  cases  where  the  symptoms  observed  direct  the 
attention  to  the  genital  tract. 


PHYSICAL   EXAMINATION  7 

Examination  of  the  Abdomen. — To  make  an  abdominal 
examination,  the  patient  should  lie  on  a  bed  or  on  an  ex- 
amining table;  the  legs  stretched  out,  the  arms  alongside  the 
body.  The  patient  should  be  directed  to  breathe  quietly  and 
to  let  herself  relax  the  muscles  of  the  abdominal  wall,  a  con- 
dition much  more  difficult  to  obtain,  than  would  be  believed  at 
first  sight. 

Before  beginning  this  examination,  it  should  always  be  seen 
to  that  the  rectum  and  bladder  are  empty.  It  is  a  good  thing 
to  provide  one's  self  with  a  dermographic  pencil  so  that  one 
may  at  the  time  fix  the  results  of  the  examination  by  drawing 
on  the  integument  the  outlines  of  the  tumors  which  have  been 
determined  by  the  various  methods  of  exploration.  This  outline 
has  not  only  the  advantage  of  giving  to  the  observer  a  resume  of 
the  results  of  his  physical  examination  but  it  may  also  at  the  same 
time  facilitate  the  diagnosis  by  giving  a  graphic  representation 
of  the  most  saliant  and  significant  points,  that  successive  and 
as  it  were  "parcelled  out"  examination  would  not  have  made 
so  clear. 

This  precaution  having  been  taken,  the  abdomen  is  exposed. 

Inspection. — Simple  inspection  serves  to  ascertain  any  modi- 
fications of  the  integument  there  may  be  (venous  or  lymphatic 
varices,  pigmentation,  streaks,  etc.),  the  existence  of  a  general 
enlargement  of  the  abdomen  or  any  limited  projection.  In  this 
last  case  it  is  to  be  determined  what  the  precise  position  of  the 
swelling  is,  whether  it  is  median  or  lateral,  whether  it  is  smooth 
or  nodular,  and  if  it  moves  or  not  with  respiration.  The  form 
of  the  abdomen  is  sometimes  of  itself  sufficient  to  suggest  cer- 
tain maladies ;  an  abdomen  of  a  flattened  ovoid  shape  with  bulg- 
ing of  the  flanks  suggests  ascites;  a  bossy  abdomen,  jutting  out 
markedly  in  front,  a  fibroma ;  an  enormous  belly  falling  down 
over  the  thighs,  an  ovarian  cyst,  etc. 

Percussion. — By  percussion  one  can  determine  the  form  of 
the  zone  of  dullness,  noting  if  this  form  is  modified  by  changing 
the  patient's  position.  It  is  thus  possible  by  this  mode  of  explo- 
ration alone  to  make  certain  diagnoses  and  to  differentiate,  for 
example,  between  an  ascites  and  an  ovarian  cyst. 

Palpation. — It  is  palpation  which  furnished,  in  most  cases, 
most  valuable  and  complete  information.  This  palpation  should 


8  THE   CLINICAL   EXAMINATION   IN  GYNECOLOGY 

be  done  softly,  not  with  the  ends  of  the  fingers  but  with  the 
entire  palmar  surface  of  the  hand1  placed  flat  on  the  abdominal 
wall  which  is  gently  pressed  in,  encouraging  the  patient  to  breathe 
quietly  and  thus  gain  ground  at  each  expiration. 

With  patience  one  can  almost  always  triumph  by  the  method 
against  the  muscular  contraction  which  opposes  the  hand  of  the 
surgeon  in  pusillanimous  and  nervous  patients.2  On  the  other 
hand,  the  thick  layer  of  fat  which  lines  certain  abdominal  walls 
renders  palpation  as  difficult  in  its  execution  as  uncertain  in  its 
results. 

In  most  cases,  it  is  easy  to  determine  by  palpation  the  presence 
of  a  tumor,  but  sometimes  one  may  have  considerable  doubt  as  to 
its  exact  position  with  reference  to  the  different  planes  of  the 
abdominal  wall. 

Ventral  hernias  are  easily  recognized  by  the  bulging  they 
make  when  the  rectus  muscles  are  contracted,  by  their  total 
or  partial  reducability,  and  by  the  depressability  existing  between 
the  separate  recti. 

When  a  true  tumor  is  present,  it  is  again  easy  to  determine  if 
it  is  parietal  or  intraabdominal  by  an  exceedingly  simple  little 
maneuver.  While  the  patient  is  lying  down,  ask  her  to  sit  up 
while  the  surgeon  continue  palpating  the  tumor.  If  the  contrac- 
tion of  the  abdominal  muscles  caused  by  this  movement  renders 
the  tumor  more  prominent,  at  the  same  time  not  affecting  its  mo- 
bility in  front  of  the  contracted  muscles,  the  tumor  is  premuscular 
parietal.  If,  while  remaining  prominent  and  clearly  preceptible, 
the  tumor  is  immobilized  by  the  muscular  contraction,  one  is 
dealing  with  an  intramuscular  parietal  tumor.  Finally,  if  the 
contracted  muscle  mask  the  tumor  so  that  it  is  lost  on  exploration, 
it  is  a  case  of  intraabdominal  tumor.  Having  localized  the 
tumor,  its  form,  mobility,  and  consistence  must  be  determined. 
Is  it  soft  or  hard ;  fluctuating  or  not  ?  Sometimes  palpation  gives 
sensations  of  a  quite  particular  significance,  such  as  the  crepita- 
tion characteristic  of  peritoneal  rubbing.  If  the  tumor  hardens 
under  the  hand,  one  may  be  sure  it  is  a  case  of  gravid  uterus.  In 

1  The  hand  should  be  warm,  otherwise  a  disagreeable  sensation  is  caused  by  the 
application  of  a  cold  hand  on  the  skin  of  the  abdomen,  which  may  cause  defensive  con- 
tractions of  the  abdominal  wall  hindering  the  exploration. 

2  One  must  guard  against  certain  localized  contractions  which  give  falsely  the  sensa- 
tion of  a  tumor. 


PHYSICAL  EXAMINATION  9 

other  cases  there  is  a  sensation  of  a  hard,  mobile  mass,  striking 
against  the  walls  at  times,  and  seeming  to  float  in  a  cavity;  in 
brief,  one  has  the  sensation  of  ballottement.  This  is  again  in 
most  cases  an  obstetrical  symptom  due  to  the  movements  of  a 
fetus  floating  in  the  amniotic  fluid.  Certain  tumors  bathed  in 
the  liquid  of  an  ascites  may  give  a  similar  sensation. 

Auscultation. — Auscultation  has  not  much  importance  in 
gynecology.  It  is  of  importance  in  diagnosing  pregnancy,  and  it 
is  quite  unnecessary  to  mention  here  the  pathognomonic  signifi- 
cance of  the  sounds  of  the  fetal  heart  in  this  connection.  The 
uterine  souffle  is  of  much  less  interest,  because  if  it  is  met  with 
in  pregnancy  it  is  equally  of  common  occurrence  in  cases  of 
large  tumors,  particularly  fibromas. 

Method  of  Genital  Examination. — The  patient  is  placed  lying 
on  her  back,  the  legs  flexed  on  the  thighs  and  these  flexed  on 
the  pelvis  and  placed  in  slight  abduction.  It  is  a  good  thing  for 


111 li!!'i'.!!!!  11  ifl :i'i'i!l|  CTFI 

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FIG.  1. — Patient  in  dorsal  position. 


the  patient  to  place  her  closed  fists  under  her  so  as  to  raise  the 
pelvis  slightly  (Fig.  1). 

Inspection. — One  should  start  with  the  examination  of  the 
vulva.  After  having  noted  the  aspect  of  the  cutaneous  side  of 
the  labia  majora,  separate  them  and  examine  successively  the 
other  parts  of  the  vulva  (labia  minora,  clitoris,  vestibule,  urethral 
orifice,  hymen  or  carunculse  myrtif ormes) .  The  condition  of  the 
fourchette,  which  may  be  torn,  should  be  observed,  and  before 
proceeding  further  with  the  examination  it  is  as  well  to  ask  the 
patient  to  bear  down  which  may  cause  some  bulging  indicating 
an  anterior  or  posterior  colpocele  which  did  not  exist  before  the 
effort. 


10  THE  CLINICAL  EXAMINATION  IN  GYNECOLOGY 

Vaginal  Examination. — After  examining  in  this  manner  the 
vulva,  the  next  thing  to  do  is  to  make  a  vaginal  examination. 
The  hands  should  first  be  disinfected  then  methodically  introduce 
the  vaselined  finger  into  the  vagina  by  applying  it  first  to  the 
perineum  and  bring  it  gradually  forward  until  it  encounters  the 
fourchette;  it  then  suffices  to  lightly  press  on  this  to  enter,  a 
coup  sur,  the  vagina. 

Making  its  way  gradually,  the  finger  should  explore  the 
walls  of  the  vagina,  noting  the  state  of  the  mucous  membrane, 
the  existence  of  ulcerations  or  of  fistulous  orifices  that  may  be 
there,  the  protrusion  of  tumors,  and,  lastly,  any  foreign  bodies. 
Continuing  to  insinuate  the  finger  gently  the  surgeon  meets  the 
cervix.  However  inexperienced  he  may  be,  he  recognizes  it 
easily  by  its  rounded  form,  its  firm  consistence  usually  com- 
pared to  the  tip  of  the  nose  where  the  cartilages  of  the  lobules 
meet. 

The  condition  of  the  vaginal  fornices  which  surround  it 
should  first  claim  the  attention.  Any  increase  in  their  depth 
indicates  prolapse.  Normally  the  posterior  fornix  is  deeper 
than  the  anterior.  Its  depth,  however,  should  not  be  excessive; 
that  would  be  indicative  of  a  malformation  or  a  false  marital 
passage.  The  pliancy  of  these  fornices  should  be  noted  at  the 
same  time,  also  their  obliteration  by  a  juxta-uterine  tumor.  In 
case  of  a  tumor,  its  characters  should  be  determined  which  can 
be  better  done  afterward  by  a  bimanual  examination.  Having 
rapidly  acquired  an  impression  of  the  condition  of  the  vaginal 
fornices,  the  surgeon  turns  to  the  examination  of  the  cervix.  What 
is  its  situation  ?  Is  it  near  the  vulva,  indicating  a  prolapsed 
uterus  ?  Is  it  lying  "en  masse"  forward  against  the  symphysis  or 
backward  toward  the  concavity  of  the  sacrum  ?  In  which  direc- 
tion does  the  orifice  look  ?  Does  it  look,  as  it  normally  does, 
down  and  back?  Is  the  orifice  rounded  as  in  a  nullipara  or 
punctiform  at  the  end  of  a  long  and  conical  neck  ?  Or  is  it,  on 
the  contrary,  the  transversely  split  orifice  of  a  woman  who  has 
had  children  ?  It  is  narrowed  or  dilated  and,  in  this  last  case,  does 
it  give  passage  to  a  polypus,  or  to  an  epitheliomatous  intracerv- 
ical  vegetation,  placental  debris,  or  simply  to  the  cervical  mucous 
membrane  in  ectropion  ?  Are  there  any  tears  present,  and  if 
these  tears  are  commissural  do  they  continue  toward  the 


PHYSICAL  EXAMINATION  11 

lateral  fornix  as  cicatricial  indurations  ?  The  examination  of 
the  cervix  is  finished  by  the  appreciation  of  its  volume  and  con- 
sistence, and  any  irregularities  of  its  surface.  This  examina- 
tion, more  rapidly  made  than  described,  gives  fuller  information 
than  may  be  acquired  by  inspection  through  a  speculum  however 
prolonged. 

But,  however  precious  the  information  acquired  by  this 
method  of  examination  alone,  it  is  not  to  be  compared  with 
a  combination  of  this  method  and  abdominal  palpation. 

Bimanual  Examination. — Vaginal  examination  and  abdominal 
palpation  combined  constitute  the  most  precious  of  the  methods 
of  gynecological  examination.  This  is  really  not  a  new  method 
of  examination;  although  every  day  in  Germany  one  hears 
that  the  merit  of  having  invented  it  some  twenty  years  ago  be- 
longs to  Schultze,  we  know  in  France  that  it  dates  back  much 
further  and  that  introduced  by  Rinzos  at  the  beginning  of  the 
nineteenth  century,  it  was  later  brought  into  general  use  by  Vel- 
peau  and  Courty. 

To  put  into  practice  the  bimanual  method  of  examination  the 
palmar  surface  of  the  fingers  and  not  radial  border  of  the  index- 
finger  should  be  used.  One  finger  or  better  two,  if  the  vagina 
is  large,  are  introduced  and  kept  in  contact  with  the  cervix. 
The  external  hand,  placed  flat  on  the  hypogastric  region,  exerts 
progressive  pressure  on  the  abdominal  wall,  while  the  patient 
breathes  gently  and  does  not  contract  her  muscles.  It  is  of  ad- 
vantage to  talk  to  her  and  gain  her  confidence.  If  the  vagina  is 
deep,  the  sacral  region  should  be  slightly  raised  by  getting  the 
patient  to  put  her  fists  underneath,  press  firmly  against  the 
perineum  the  interdigital  commissure,  wrhilst  the  index-finger  is 
in  the  vagina,  the  median  in  the  internatal  fold,  and  the  thumb 
inclined  toward  the  anal  cleft.  By  this  method  one  can  lengthen 
the  finger  from  4  to  6  cm.  The  hypogastric  hand  endeavors  to 
hook  the  fundus  of  the  uterus  and  to  seize  the  body  which  is 
supported  by  the  fingers  in  the  vagina  pressing  in  the  anterior 
fornix  where  the  normally  anteflexed  uterus  should  lie  (Fig.  2). 
If  the  body  of  the  uterus  cannot  be  discovered  by  this  maneuver 
then  it  is  not  in  its  normal  position;  it  is  then  probably  retro- 
verted  and  may  be  discovered  by  supporting  it  with  the  fingers  in 
the  posterior  fornix.  Once  the  uterus  is  seized  it  is  easy  by 


12 


THE   CLINICAL   EXAMINATION   IN   GYNECOLOGY 


combined  palpation  to  appreciate  its  mobility  in  all  directions, 
not  forgetting  that  if  the  fixation  of  the  uterus  indicates  a  patho- 
logical condition  an  undue  mobility  may  inversely  of  itself  be  a 
source  of  trouble. 

After  having  thus  established  the  situation  and  mobility  of 
the  uterus,  by  combined  palpation  one  can  appreciate  its  con- 
sistence and  volume  that  may  be  expressed  by  comparing  it 


FIG.  2. — Section  of  pelvis  showing  the  projection  of  the  cervix  into  the  vagina, 
the  normal  anteflexion  of  the  uterus,  also  that  the  depth  of  the  posterior  fornix  is  greater 
than  that  of  the  anterior. 

with  the  volume  of  a  gravid  uterus  at  a  given  period  of  gestation 
or  by  indicating  the  height  of  the  fundus  above  the  superior 
border  of  the  pubic  symphysis.  Bimanual  examination  allows 
also  the  exploration  of  the  broad  ligaments  and  adnexa.  To 
effect  this,  the  vaginal  finger  should  be  placed  in  one  of  the  lateral 
fornices  and  then  pressing  with  the  hypogastric  hand  the  abdomi- 


PHYSICAL  EXAMINATION  3 

nal  wall  above  the  Arcus  Fallopii  of  the  same  side  endeavor 
should  be  made  to  seize  the  adnexa  between  the  vaginal  fingers 
and  the  external  hand. 

To  reach  most  easily  the  right  adnexa  it  is  best  to  have  the 
right  hand  the  vaginal  hand,  and  vice  versa  to  palpate  the  left 
adnexa  it  is  best  to  make  the  vaginal  examination  with  the  left 
hand,  in  this  manner  always  turning  the  palmar  face  of  the  hand 
toward  the  side  to  be  examined. 

Except  in  cases  of  special  difficulty,  as  for  example  a  very 
fat  patient,  one  can  thus  palpate  even  healthy  adnexa  and 
appreciate  their  volume,  consistence  and  mobility. 

All  these  manipulations  of  the  bimanual  examination  become 
much  easier  when  the  patient  is  placed  with  the  pelvis  elevated, 


FIG.  3. — An  adjustable  table,  with  shoulder  rests,  used  for  pelvic  examinations. 


which  position  we  have  adopted  systematically  for  all  our  gyneco- 
logical examinations  and  which  \ve  obtain  by  aid  of  an  extremely 
simple  table  capable  of  being  tilted  at  will  (Figs.  3  and  4). 

The  intestines  fall  toward  the  diaphragm;  the  pelvic  cavity 
becomes  empty;  the  uterus  and  its  adnexa,  held  by  their  attach- 
ments to  the  pelvic  floor,  remain  only  in  place  and  separated 
from  the  intestines  which  normally  surround  them,  permit  of 
being  palpated  with  the  greatest  of  ease.  This  position  of 
elevation  of  the  pelvis  (45  degrees  inclination)  has  also  the 
advantage  of  emptying  it  of  any  tumors  that  may  have  fallen 


14 


THE   CLINICAL   EXAMINATION   IN   GYNECOLOGY 


FIG.  4. — Bimanual  examination  with  pelvis  elevated. 


I 

FIG.  5. — Hydronephrosis  fallen  into  the  pelvis ;  the  dotted  line  marks  the  position  the 
tumor  occupies  at  the  time  of  examination,  the  plain  line  the  position  occupied  on 
elevating  the  pelvis  of  the  patient. 


PHYSICAL  EXAMINATION  15 

into  it  (floating  spleen,  hydronephrosis  in  a  movable  kidney). 
Every  tumor  arising  in  the  superior  part  of  the  abdomen  returns 
to  its  place  of  origin  when  the  pelvis  is  raised  (Fig.  5).  It  can 
be  understood  all  the  advantages  accruing  from  such  a  method 
of  examination  from  a  diagnostic  point  of  view. 

Rectal  Examination. — Rectal  examination  is  made  in  the 
ordinary  manner.  After  having  covered  round  the  nail  of  the 
index-finger  with  soap,  or  better  after  having  covered  the  finger 
with  a  rubber  protector  or  one  of  gold-beater's  skin,  the  anus 
and  examining  finger  should  be  wrell  vaselined.  The  finger  is 
introduced  at  first  in  an  upward  and  forward  direction,  then 
upward  and  backward  so  as  to  feel  through  the  rectal  wall, 
the  cervix  and  body  of  the  uterus.  In  pathological  cases  the 
bulging  toward  the  rectum  of  collections  in  the  recto-uterine 
pouch,  also  the  roots  of  the  sciatic,  may  thus  be  palpated.  It  is 
a  method  of  examination  particularly  useful  in  virgins;  in  case 
of  necessity,  it  is  in  most  cases  possible  even  in  them  to  do 
a  vaginal  examination  without  defloration ;  it  suffices  to  introduce 
the  finger  extremely  gently  without  separating  the  legs.  Excep- 
tionally, in  order  to  appreciate  alterations  in  the  recto-vaginal 
septum  a  combination  of  rectal  and  vaginal  examinations  may 
be  indicated. 

Examination  with  the  Speculum. — The  speculum  does  not 
give  nearly  such  good  results  as  the  bimanual  examination. 
With  a  little  experience  the  latter  informs  us  of  all  that  we 
might  learn  by  the  use  of  the  speculum  and  in  addition  gives  us 
impressions  of  existing  conditions  which  the  speculum  is  unable 
to  do.  The  part  the  speculum  plays  in  an  examination  now- 
a-days  is  very  restricted  and  is  not  regarded  as  of  the  same 
great  importance  as  was  the  case  during  the  last  twenty  years. 
Its  use  is  contraindicated  when  any  obstruction  exists  to  its 
introduction,  such  as  a  hymen,  an  acute  inflammation,  any 
contraction,  or  in  cases  of  vaginismus,  or  finally  in  the  event 
of  a  recent  wound  of  the  vagina  or  vulva  which  the  speculum 
might  disunite.  The  forms  of  speculums  are  numerous;1  they 
can  be  classified  into  three  groups,  the  bivalve  type,  represented 

1  We  do  not  describe  here  all  the  various  models  of  specula.  Those  who  are  interested 
in  the  history  of  the  speculum  will  find  an  article  by  Jayle  (Presse  medicale,  February  10, 
1904,  p.  891)  detailing  its  history  from  the  time  of  Abbucasis  to  the  present  day. 


16 


THE   CLINICAL   EXAMINATION   IN   GYNECOLOGY 


by  Cusco's;  the  cylindrical  type  generally  employed  is  that  of 
Fergusson;  the  "duckbill"  or  single-valve  type  is  best  known 
under  the  name  of  Sims.  It  appears  useless  to  describe  here 
these  speculums  which  are  in  everyday  use.  (See  Figs.  6,  7,  8 
and  9.) 

In  a  general  way  the  valvular  speculums  have  a  fixed  point  at 
the  level  of  the  vulvar  orifice  where  a  screw  or  lever  enables  the 


FIG.  6. — Cusco's  bivalve  speculum. 


FIG.  7. — Jayle's  bivalve  with  a  double 
movement. 


blades  to  be  opened  and  thus  distend  the  vaginal  cavity  without 
affecting  the  orifice  at  the  vulva.  The  cylindrical  speculums  are 
made  of  vulcanized  rubber,  celluloid,  glass,  or  of  metal,  and  have 
one  expanded  extremity,  while  the  other  is  shaped  like  the  mouth- 
piece of  a  flute  to  facilitate  its  introduction  and  to  accommodate 
itself  better  to  the  cervix,  seeing  that  the  posterior  fornix  is 
deeper  than  the  anterior. 


FIG.  8. — Fergusson's  cylindrical  speculum.      FIG.  9. — Sims'  "duckbill"  speculum. 


In  order  to  introduce  a  bivalve  speculum,  vaseline  it  first  and 
having  separated  the  labia  with  two  fingers  of  the  left  hand,  take 
the  speculum  in  the  right  and  introduce  it  in  such  a  fashion  that 
its  "beak,"  so  to  speak,  is  parallel  to  the  main  axis  of  the  vulva. 
One  glides  it  past  the  vulvar  orifice  by  strongly  depressing  the 
fourchette,  thus  avoiding  contact  with  the  region  of  the  vestibule. 
Having  passed  the  vulva  a  rotary  movement  is  imparted  to  the 
speculum  turning  through  a  quarter  of  a  circle  by  which  the 


PHYSICAL  EXAMINATION 


17 


blades  come  to  lie  in  the  horizontal  plane  and  are  advanced 
further  into  the  vaginal  cavity.  In  the  majority  of  cases,  if  the 
vulva  is  large  enough  it  is  simpler  to  depress  the  fourchette 
strongly  with  two  fingers  of  the  left  hand  and  introduce  the 
speculum  directly  into  the  vagina.  One  should  beware  of 
pushing  in  the  speculum  recklessly,  as  the  inexperienced  usually 
do,  but  direct  it  in  the  direction  already  ascertained  by  the  digital 
examination  per  vaginam,  a  proceeding  which  should  always  be 
carried  out  as  a  preliminary  measure. 


FIG.  10. — Introduction  of  the  bivalve  speculum.  (The  speculum  is  introduced 
obliquely  in  order  to  facilitate  its  entry  into  the  vulvar  orifice  and  then  continued  hori- 
zontally when  once  in  the  vagina.) 

The  examination  of  the  cervix  is  rendered  easier  by  keeping 
in  the  center  of  the  visual  field  of  the  speculum  the  star-shaped 
formation  produced  by  the  folds  of  the  vaginal  mucous  membrane. 
Having  found  the  cervix,  the  two  blades  are  more  widely  sepa- 
rated, by  the  screw  or  lever  apparatus,  to  the  extent  required, 
but  should  avoid  a  too  great  separation,  as  this  may  produce  an 
artificial  eversion  of  the  cervix,  which  may  be  mistaken  for  a 
pathological  condition. 

To  remove  the  speculum,  begin  by  allowing  the  two  valves 
to  fall  together,  without  allowing  them  to  meet;  in  order  not  to 


18  THE   CLINICAL   EXAMINATION   IN   GYNECOLOGY 

pinch  up  the  mucous  membrane  and  to  have  an  opportunity 
of  examining  the  vaginal  walls  as  they  slowly  fold  at  the  extremity 
of  the  speculum.  The  instrument  is  withdrawn  by  a  rotatory 
movement,  the  reverse  of  that  employed  in  its  introduction. 

In  order  to  introduce  the  cylindrical  speculum  firmly  depress 
the  fourchette  and  introduce  the  tip  of  the  flute-like  mouthpiece 
of  the  speculum  below,  thus  avoiding  catching  the  inferior  part 
of  the  urethra  above;  the  speculum  is  pushed  on  toward  the 
cervix  by  progressive  rotatory  movements.  Having  found  the 
cervix,  which  should  be  enclosed  in  the  speculum,  maneuver 
the  speculum  so  that  the  projecting  or  free  portion  of  its  extremity 
is  allowed  to  occupy  the  posterior  fornix. 

If  the  univalve  speculum  is  employed,  of  which  Sims'  duckbill  is 
a  type,  we  make  a  slight  pressure  on  the  posterior  commissure 
with  the  convex  side  of  the  speculum  and  then  gently  insinuate 
it  into  the  vulvar  orifice ;  then  as  it  is  further  introduced  it  comes 
to  lie  against  the  recto- vaginal  septum.  If  it  is  gently  pushed 
a  little  further,  we  will  be  able  to  feel  a  slight  resistance  and 
then  we  know  that  we  have  reached  the  extremity  of  the  vagina. 
All  that  then  remains  is  to  press  down  the  hand  firmly,  depress 
the  fourchette,  and  at  the  same  time  to  lever  the  instrument  in 
such  a  way  as  to  apply  greatest  pressure  on  the  extremity  in  the 
vagina.  This  results  in  the  maximum  dilatation  of  the  posterior 
fornix  and  enables  us  to  see  the  cervix.  As  at  each  inspiration 
the  anterior  vaginal  wall  interferes  with  the  view  of  the  parts, 
keep  it  raised  with  a  finger  or  a  smaller  speculum  of  the  same  type, 
or  with  Sims'  special  instrument  for  the  purpose. 

3.  Appendix. 

In  some  gynecological  cases  the  examination  may  be  complicated  by  the 
necessity  of  the  surgeon  employing  a  special  technic. 

Anesthesia. — Vaginismus,  a  persistent  contraction  of  the  muscles  of  the 
abdominal  wall,  and  troubles  of  a  very  painful  nature  justify  us  in  the  employ- 
ment of  anesthesia.  Even  for  certain  examination  measures  it  may  be  used. 
Hegar  frequently  had  recourse  to  anesthesia  for  this  purpose.  He  would 
grasp  the  cervix  with  a  tenaculum  forceps,  draw  it  down  toward  the  orifice 
of  the  vagina,  hand  the  forceps  to  an  assistant,  and  then  study  the  mobility 
of  any  tumors  present  and  their  relation  to  the  uterus.  We,  however,  believe 


APPENDIX 


19 


that  by  the  bimanual  examination  and  the  Trendelenburg  position,  we  can 
dispense  with  all  these  complicated  maneuvers  and  with  anesthesia,  which 
latter  is  not  without  a  certain  element  of  gravity,  and  unfortunately  suppresses 
much  useful  information  which  may  be  gathered  from  the  investigation  of  the 
conditions  of  existing  pain. 

Left  Lateral  Position. — The  examination  in  the  left  lateral  position 
was  formerly  much  employed  by  American  gynecologists.  The  patient 
lies  on  her  left  side  on  a  firm  resistant  surface,  the  head  supported 
on  a  cushion.  The  left  arm  hangs  over  the  edge  of  the  table:  the 
thighs  and  knees  of  both  extremities  are  flexed  and  the  right  is  more  flexed 
and  carried  forward,  as  the  pelvis  is  inclined  toward  the  table,  its  movable 
contents  fall  forward  toward  the  anterior  abdominal  wall,  thus  permit- 
ting the  vagina  distending.  Sims'  duckbill  speculum  is  employed.  Raise 


FIG.  11. — Left  lateral  position. 


the  labium  major  with  the  left  hand  and  introduce  the  speculum  with  the 
concavity  of  the  blade  looking  down.  Once  past  the  vaginal  entrance,  incline 
the  instrument  slightly  back  so  that  the  concavity  looks  forward,  and  as  it 
is  gradually  introduced,  further  support  it  continually  against  the  posterior 
vaginal  wall.  When  the  blade  is  in  place,  hand  it  to  an  assistant  who  with 
his  right  hand  draws  it  backward  and  slightly  across  the  upper  buttock, 
while  with  his  left  hand  he  raises  the  upper  labium  major  and  the  upper 
buttock.  This  position  permits  of  a  good  examination  of  the  vagina.  At 
all  times  when  there  are  inflammatory  exudates  in  the  pelvis  the  uterus 
remains  fixed  and  the  vagina  does  not  distend  well.  This  mode  of  examina- 
tion is  not  much  employed  in  France. 

Standing  Position. — The  patient's  back  rests  against  a  wall  or  a  piece 
of  furniture.  The  surgeon  kneels  on  his  left  knee,  supporting  his  elbow  on 
his  semiflexed  right  knee,  and  in  this  position  he  makes  a  digital  vaginal 
examination. 

This  method  is  indicated  in  special  cases  where  one  wishes  to  deter- 
mine the  degree  of  a  prolapse  and  particularly  to  investigate  the  efficacy 


20 


THE   CLINICAL   EXAMINATION   IN    GYNECOLOGY 


of  a  pessary  to  remedy  the  prolapse;  it  is  useful  also  to  determine  fetal 
"ballottement." 

Knee-elbow  Position. — In  this  position,  greatly  used  in  America,  the 
patient  kneels  on  the  table,  the  trunk  sharply  inclined  downward  and  for- 
ward; the  head  on  the  table  is  turned  to  one  side  or  the  other  and  the  breasts 
as  closely  in  contact  with  the  table  as  possible.  In  this  position  the  pelvic 
contents  fall  toward  the  anterior  abdominal  wall  as  in  the  left  lateral  position, 
but  more  markedly;  also  the  moment  that  one  partly  opens  the  vagina  by 
the  introduction  of  a  simple  valve  speculum,  which  lifts  up  the  fourchette, 
the  air  enters  and  dilates  the  vagina,  enabling  us  to  examine  its  walls  quite 
easily.  It  is  the  best  position  for  the  examination  of  a  virgin. 


Fig.  12. — Genu-pectoral  position. 

One  has  only  to  introduce  through  the  orifice  of  the  hymen  (while  the 
patient  is  in  the  knee-elbow  position)  a  tube  provided  with  a  mandrin  of  8 
to  15  mm.  (^"  —  |-")  diameter.  The  tube  being  introduced,  the  mandrin 
is  drawn  out  and  the  vagina  distending  as  a  result  of  the  entry  of  air,  it 
may  be  easily  examined  in  its  entirety  provided  the  light  is  sufficient. 

Hysteroscopy. — Hysteroscopy  or  uterine  endoscopy  was  recommended 
in  France  by  Duplay  and  Clado  who  used  a  tube  and  a  photophore  or  light- 
producing  apparatus.  David,1  who  has  recently  taken  up  the  study  of  this 
question,  uses  a  tube  with  an  internal  light  like  Valentine's  urethroscope,  but 
closed  at  its  extremity  with  glass  to  avoid  contact  of  the  lamp  with  the  blood 
oozing  from  the  uterine  mucous  membrane.  The  uterus  is  first  dilated  and 
then  drawn  down.  The  tube  fitted  with  a  mandrin  is  introduced  into  the 
uterus  as  far  as  the  f undus ;  the  mandrin  is  then  withdrawn  and  replaced  by 

'Proutiere  (Z),  Contribution  a  V etude  de  I'hysteroscopie.  Th.  de  Paris,  1898-1899,  No. 
69. — Beuttner,  Cent.  Bl.f.  Gyn.,  Leipzig,  1898,  No.  22,  p.  580. — David,  Annales  de  Gyn. 
et  d'Obstet.,  Paris,  Sept.,  1908,  p.  513. 


APPENDIX  21 

the  internal  tube  fitted  with  glass  over  its  extremity.  Once  the  lamp  is  in 
place,  one  can  begin  by  examining  the  internal  surface  of  the  uterus,  com- 
mencing at  the  f  undus  and  then  the  rest  of  the  cavity,  gradually  withdrawing 
and  at  the  same  time  circumducting  the  instrument  which  enables  the  light 


FIGS.  13,  14,  and  15. — David's  hysteroscope. 

Above  the  instrument  complete.     Below  the  external  tube  with  its  mandrin  and  then 

the  internal  tube. 

in  the  tube  to  make  a  complete  tour,  so  to  speak,  of  the  whole  of  the  uterine 
cavity. 

Up  to  the  present,  this  method  of  examination  is  not  common.     Person- 
ally, we  have  never  had  recourse  to  it. 


CHAPTER  II. 

MINOR  GYNECOLOGY. 

Contents. — Vaginal  injections. — Vaginal  medication. — To  tampon  the 
vagina. — Catheterization  of  the  uterus. — Dilatation  of  the  uterus:  first, 
rapidly;  second,  slowly. — Intrauterine  medication  (lavages,  injections, 
local  applications  and  caustics). — Drainage  of  the  uterus. — Atmokausis. 
— Cestokausis. — Bier's  method. — Pessaries. — Curetting  of  the  uterus. 

1.  Vaginal  Injections. 

The  simplicity  of  the  treatment  of  utero-vaginal  affections  by 
injections  has  made  this  method  one  used  for  all  time.  For  a 
long  time  the  incontestable  influence  they  exert  in  certain  cases 
has  been  the  subject  of  much  study,  and  whether  this  be  due  to 
their  mechanical  or  their  therapeutic  action  is  the  question  at 
issue.  It  is  realized  to-day,  however,  that  a  great  part  of  their 
action  is  due  to  the  heat  they  contain. 


FIG.  16. — Douche-can  for  vaginal  injections. 

Instruments. — The  ordinary  douche-can  is  most  generally 
used  now-a-days.  It  consists  of  a  can  holding  1  or  2  liters  (35  to 
70  ounces),  fitted  with  a  cock  at  its  base,  to  which  one  can  fit  a 
rubber  tube  about  2  meters  long  (7  feet)  and  about  1  centimeter 
(2/5  inch)  in  diameter. 

The  type  most  universally  employed  is  the  half  cylindrical 
can  with  a  cock  projecting  from  its  side.  This  can,  generally 

22 


VAGINAL  INJECTIONS 


23 


enamelled,  is  hooked  on  to  the  wall  on  its  flat  side  or  made  to 
stand  on  a  piece  of  furniture  or  even  held  by  a  handle. 

There   are   also   forms   made   for   use   while   travelling;   for 


FIG.  17. — Budin's  apparatus. 

example,  Budin's  appara- 
tus (Fig.  17),  the  siphon-in- 
jector (Higginson's  syringe), 
or  Doleris'  india-rubber 
bag. 

It  is  unnecessary  to  de- 
scribe Budin's  apparatus  and 
Doleris'  bag,  so  we  will 
briefly  give  the  description 

FIG.  18.— Rubber  bag  for  vaginal  injections.     Qf     tne     siphon-injector     or 

Higginson's  syringe.  It  is  a  simple  rubber  tube  with  a  hook- 
like  extremity  enabling  it  to  be  attached  to  the  side  of  any  vessel, 
and  a  bulbous  projection  about  its  middle  which  controls  the 
amount  of  liquid  passing  through  the  tube  according  as  little 
or  increased  pressure  is  placed  upon  the  bulb. 


24 


MINOR   GYNECOLOGY 


Cannulas  are  usually  made  of  glass,  slightly  expanded  at 
their  extremity,  and  having  lateral  openings  and  not  terminal 
ones  in  order  to  avoid  the  projection  of  fluids  into  the  cervix. 

Technic. — It  might  be  thought  sufficient  to  simply  recommend 
a  woman  to  take  vaginal  injections  and  nothing  more,  and  the 
current  practice  is  for  women  to  make  these  injections  without 
cause  and  without  care  and  this  often  results  in  doing  more  harm 
than  good.  An  injection  may  result  in  the  introduction  into  the 


FIG.  19. — Glass  vaginal  cannula. 

vagina,  cervix,  or  uterine  cavity  of  septic  material,  against  which 
these  organs  are  naturally  protected.  It  is  of  great  importance 
therefore  that  everything  coming  into  contact  with  the  vaginal 
cavity  should  be  aseptic,  and  the  hands  should  be  carefully 
washed. 

The  position  of  the  patient  for  taking  the  douche  is  of  great 
importance  and  should  be  always  described  in  detail  to  the 
patient  by  the  doctor.  Ignorant  of  the  correct  method,  the 
patient  sometimes  makes  the  injections  in  the  standing  position, 
or  seated  astride  of  a  bath  or  in  a  crouching  position  over  a  bowl. 


FIG.  20. — Bed-slipper  pan. 

Under  these  conditions  the  vaginal  cavity  is  almost  completely 
effaced  by  the  abdominal  pressure  and  the  injection  is  unable 
to  penetrate  a  very  little  distance,  so  that,  if  it  be  employed  for  its 
external  effect  upon  the  cervix,  a  fond  illusion  is  the  only  result. 
All  injections  should  be  taken  with  the  patient  lying  down,  a 
vessel  of  appropriate  form  beneath  the  buttocks  and  perineum. 
This  possesses  the  advantages  of  raising  the  pelvis  and  of  causing 
the  vagina  to  open  out. 


VAGINAL  INJECTIONS 


25 


It  is  then  freely  irrigated  and  a  certain  quantity  of  fluid 
remaining  in  the  cavity  forms  a  sort  of  prolonged  bath  of 
undoubted  advantage.  The  can  is  hooked  up  to  the  wall  about 
50  cm.  (20  inches)  above  the  level  of  the  bed.  Grasp  the  cannula 
at  its  base  in  order  to  avoid  any  contact  with  the  free  extremity, 
and  then  release  the  stop-cock  on  the  tubing  so  as  to  drive  any 
air  out  of  the  tube  and  to  get  rid  of  the  first  flow  of  water  which 
is  cold.  The  cannula  is  then  introduced  into  the  vagina,  and 
directed  at  first  backward,  and  then  partly  release  the  stop-cock 
so  that  the  lotion  is  slowly  allowed  to  run.  Then  rotate  the 
cannula  in  the  vagina  so  that  the  posterior,  lateral,  and  anterior 
fornices  are  successively  washed  out.  If  the  vaginal  orifice 
contracts  and  does  not  allow  the  fluid  to  escape,  lightly  press 
down  the  fourchette  with  the  cannula,  so  as  to  cause  the  vulva 
to  partially  gape. 

Having  finished  the  injection,  ask  the  patient  to  lie  flat  on 


FIG.  21. — Double  current  cannula  for  very  hot  vaginal  irrigations. 

her  back  for  about  a  quarter  of  an  hour,  or  if  she  gets  up  imme- 
diately ask  her  to  cough  or  bear  down  in  order  to  evacuate  the 
vagina  of  its  contents  which  w^ould  slowly  trickle  away  and  wet 
her  chemise,  did  we  not  observe  this  precaution.  Wipe  the 
external  genitals  with  a  clean  towel  or  absorbent  wool.  Put  the 
cannula  in  a  vessel  containing  corrosive  sublimate  1  per  1000  and 
replace  the  rubber  tubing  in  the  can,  which  is  covered  with  a 
clean  towel. 

The  quantity  of  fluid  injected  is  about  1  to  1  1-2  liters  (35 
to  52  ounces).  The  temperature  should  be  about  that  of  the 
body.  In  certain  cases  it  may  be  necessary  to  order  very  hot 
injections,  about  48  to  50°  (124  to  130°  Fahrenheit),  and  it  is 
noticed  that  while  these  are  well  tolerated  in  the  vaginal  cavity 


26  MINOR  GYNECOLOGY 

they  burn  on  running  out.  We  adopt,  therefore,  certain  pre- 
cautions, and  place  on  the  perineum  a  sponge  soaked  with 
cold  water  or  vaseline  the  skin  surface  well.  If  these  means 
are  insufficient,  use  a  special  cannula  which  permits  of  a  back 
flow  through  a  tube  and  allows  no  contact  of  the  hot  water  with 
the  external  vulva  and  perineum.  The  figure  admirably  illus- 
trates the  apparatus  used  for  this  purpose.  This  special  cannula 
is  used  when  it  is  necessary  to  use  large  quantities  of  hot  water; 
at  Luxeil  as  much  as  60  to  80  liters  (105-140  pints)  are  used,  and 
the  irrigation  lasts  about  15  minutes. 

The  nature  of  the  liquid  employed  need  not  detain  us  here, 
and  it  is  ancient  history  now  to  use  the  division  of  injections 
into  astringents,  alteratives,  emollients,  and  narcotics. 

One  is  often  restricted  to  the  use  of  an  aseptic  liquid  such  as 
boiled  water.  Boracic  acid,  which  is  of  such  popular  use  that  it 
is  sold  by  grocers  and  other  tradesmen,  has  of  course  no  special 
effect. 

Sublimate,1  1  or  2  parts  to  4000;  copper  sulphate,  5  parts  to 
1000;  alum,  30  parts  to  1000;  Labarraque's  liquor,  25  parts  to 
1000;  tincture  of  iodine,  1  or  2  teaspoonfuls  to  the  liter;  1  or  2 
teaspoonfuls  of  lysol  to  the  liter,  and  laniodol,  1  part  to  100,  or 
using  a  tablespoonful  to  a  liter  of  water  and  a  solution  of  for- 
maldehyde 1  to  10,000,  have  all  been  recommended. 

Permanganate  of  potash  and  hydrogen  peroxide,  the  former 
in  a  strength  of  1  to  4000  and  the  latter  3  or  4  volumes,  are 
strongly  recommended. 

Astringent  injections  are  also  useful:  Decoctions  of  camo- 
mile, walnut  leaves  or  oak  bark  are  all  useful.  These  decoc- 
tions have  the  advantage  in  that  they  force  the  patient  to 
boil  the  water  she  uses.  The  active  principle  tannin  is  also 
used  and  about  3  grams  (45  grains)  are  used  to  a  liter  (35  ounces) 
of  boiling  water. 

Referring  to  alkaline  injections  \ve  can  recommend  10  grams 
(250  grains)  of  bicarbonate  of  sodium  added  to  every  liter  of  boiled 
water. 

Indications  and  Contraindications. — Injections  for  cleanli- 
ness, so  to  speak,  are  useless.  Used  after  coitus  they  are  often 

1  The  simplest  method  is  to  make  packets  of  corrosive  sublimate  and  a  little  tartaric 
acid  to  help  it  to  dissolve,  and  add  a  coloring  agent  to  avoid  error  (sublimate  0.50  tar- 
taric acid,  15  grs.  indigo  carmin. 


VAGINAL  MEDICATION  27 

a  cause  of  sterility.  During  pregnancy  in  healthy  women  they 
are  injurious  in  that  they  diminish  the  bactericidal  power  of  the 
vaginal  secretions  so  clearly  established  by  Doderlein,  Kronig, 
and  others.  In  addition,  they  may  even  cause  abortion  in 
exceptional  instances.  It  is  not  our  intention  here  to  advise 
against  vaginal  injections,  but  merely  to  suggest  more  restraint 
in  their  use  for  purposes  of  cleanliness.  They  are  of  use  in 
women  who  are  wearing  pessaries,  and  in  such  cases  they  should 
be  continued  even  during  the  menstrual  period,  merely  taking 
the  simple  precaution  of  giving  them  under  gentle  pressure 
and  luke-warm  so  as  not  to  excite  uterine  contractions.  In 
such  cases  avoid  the  employment  of  drugs  that  might  become 
deposited  on  the  pessary  and  render  it  rough  and  irritating  to 
the  vagina. 

As  therapeutic  agents  injections  have  many  indications  as  we 
will  see  further  on  in  the  treatment  of  vaginitis,  some  forms  of 
metritis,  and  even  of  certain  chronic  periuterine  inflammations. 
Hot  injections  with  their  vasoconstrictor  action  are  indicated  in 
all  hemorrhages,  metrorrhagias,  and  menorrhagias.  There  is 
reason  to  suspect  their  action  in  pelvic  suppuration  in  the  acute 
stage  and  in  recent  periuterine  exudates,  because  they  may 
determine  an  aggravation  of  the  pain  and  of  preexisting  troubles. 

2.  Vaginal  Medication. 

Intravaginal  medication  in  the  form  of  applications  is  gener- 
ally made  after  the  speculum,  has  been  applied;  perhaps  as 
brushed  out  with  (solution  of  nitrate  of  silver,  tincture  of 
iodine,  etc.) ;  perhaps  as  an  insufflation  (iodoform,  alum,  etc.) ; 
or  as  a  tampon.  For  the  last-named  kind  of  application,  by  far 
the  most  employed,  use  a  tampon  of  absorbent  wool  fastened 
to  a  stout  piece  of  thread  which  should  be  of  sufficient  length  to 
lie  between  the  lips  of  the  vulva,  so  that  it  may  be  drawn  out  by 
the  patient  at  any  time  without  recourse  to  the  medical  man's 
aid.  The  tampon,  having  been  sterilized,  may  be  a  vehicle  for  the 
application  of  drugs  in  solution,  ointment,  or  powder.  After 
soaking  the  tampon  in  the  solution  to  be  used  squeeze  out  the 
superfluous  fluid  so  that  it  does  not  keep  trickling  away  when  once 
the  tampon  is  in  position.  The  most  varied  applications  are 


28  MINOR   GYNECOLOGY 

used,  and  of  these  glycerine  deserves  special  mention.  Intro- 
duced into  gynecological  therapeutics  by  Marion  Sims,  it  rapidly 
demonstrated  the  possession  of  a  special  action.  Eagerly  absorb- 
ent of  water,  it  excites  an  abundant  aqueous  flow,  a  sort  of  sero- 
mucous  emission,  and  thanks  to  its  hydragogue  properties  it  is  one 
of  the  best  vaginal  applications.  It  is  used  pure  or  with  such 
agents  as  iodoform,  1  to  10;  ichthyol,  1  to  20;  resorcine,  1  to  10; 
acid  lactic,  1  to  30,  etc. 

In  order  to  permit  patients  themselves  to  introduce  therapeu- 
tic agents,  we  advise,  sometimes,  the  use  of  solid  ovules  with  a 
glycerine  base,  which  dissolve  in  the  interior  of  the  vaginal  cavity. 

Guinard  has  praised  calcium  carbure  in  cases  of  inoperable  cancer. 
Having  cleaned  the  parts,  a  piece  of  chloride  of  calcium  is  inserted  into  the  os 
uteri  and  a  tampon  immediately  introduced.  The  tampon  is  of  iodoform 
gauze.  After  two  or  three  days  remove  the  tampon.  The  carbure  of  calcium 
is  reinserted  according  as  may  be  necessary.  The  method  does  not  appear 
to  have  found  many  adherents.1 

3.  Tamponing  of  the  Vagina. 

The  tamponing  of  the  vagina  has  many  indications : 

(1)  Application  of  an  external  application  to  the  cervix  and 
to  a  part  of  the  vaginal  mucous  membrane. 

(2)  To  maintain  in  the  uterine  cavity  a  solid  pencil  or  bougie 
of  some  medicinal  substance  or  a  laminaria  tent  "or  a  drain. 

(3)  To  support  a  uterus  which  tends  to  prolapse  or  the  reduc- 
tion of  a  uterine  deviation  produced  by  manual  manipulations. 

(4)  Arrest  of  uterine  hemorrhage. 

(5)  As  a  means  of  reducing  certain  inflammatory  conditions. 

The  first  two  cases  of  the  tamponing  will  require  no  explana- 
tion ;  but  we  consider  them  as  coming  under  the  heading  of  a  sim- 
ple vaginal  dressing  which  we  have  described  under  medication. 

It  is  quite  different  when  plugging  is  done  for  uterine  hemor- 
rhage. It  must  be  done  according  to  certain  rules  if  we  wish 
for  success.  We  observe  the  same  rules  as  in  cases  where  we 
wish  to  support  a  uterus  tending  to  prolapse;  that  is  to  say,  we 
endeavor  to  get  a  stimulant  action  and  to  hasten  the  absorption 
of  periuterine  exudates.  Tamponing  for  this  latter  was  recom- 

1  Livet,  The  Employment  of  Calcium  Carbure  in  Surgery.  Th.  de  Paris,  1895-96, 
No.  403. 


CATHETERIZATION  OF  THE  UTERUS  29 

mended  in  the  United  States  by  Taliafero,  and  is  often  described 
under  the  name  of  columnization  of  the  vagina. 

Is  the  action  of  this  agent  as  extensive  as  one  would  like  ? 

We  venture  to  affirm  that  it  is,  but  as  it  is  a  method  of  treat- 
ment, incontestably  anodyne,  it  can  be  tried  in  patients  with  an 
enlarged  uterus  with  less  true  salpingitis  than  remnants  of  peri- 
toneal exudates,  described  as  Douglassitis,  troubles  insufficient 
in  themselves  to  demand  an  operation  of  removal,  but  nevertheless 
giving  rise  to  pain. 

This  plugging  is  carried  out  in  the  following  manner:  First, 
place  a  large  tampon  in  the  posterior  fornix  and  then  successively 
smaller  tampons  in  the  anterior  and  lateral  fornices.  These  tam- 
pons should  fill  up  the  fornices  and  be  on  a  level  with  the  external 
os.  They  should  be  firmly  rolled  and  compact  in  order  to  com- 
press well.  Their  being  placed  in  position  is  the  most  important 
part  of  the  columnization ;  this  is  carried  out  by  filling  the  vagina 
entirely  with  tampons  moderately  compact.  In  order  to  pack  the 
vagina  use  tampons  of  wool  and  gauze  impregnated  with  glycerine 
and  dusted  with  iodoform. 

Restricted  to  the  above  typed  case  and  methodically  applied, 
such  columnization  may  give  good  results,  and  any  patient  with  a 
retroflexed  uterus,  who  cannot  put  up  any  longer  with  a  pessary, 
will  be  able  once  more  to  wear  one  after  the  lapse  of  a  varying 
interval  during  which  this  methodical  plugging  of  the  vagina  is 
carefully  carried  out. 

4.  Catheterization  of  the  Uterus. 

Instruments  Required. — Uterine  catheterization  or  hyster- 
ometry  can  be  carried  out  with  simple  urethral  bougies  or  special 
instruments  called  sounds.  Gum  elastic  urethral  bougies  may 


FIG.  22. — Malleable  sound  without  index. 

be  used  in  sizes  from  8  to  12.     Sounds  may  be  rigid  or,  better, 
malleable.     The  body  is  usually  about  15  cm.  long  (6  inches) 
with  a  smooth  olive  tip,  mounted  on  a  narrowed  neck  and  having 
a  flattened  anterior  surface  graduated  with  centimeter  indices. 
The  indicator  fitted  to  most  sounds  is  to  our  idea  useless  and 


30  MINOR   GYNECOLOGY 

renders  them  difficult  to  clean,  and  presents  no  advantage  what- 
soever. 

Technic. — The  employment  of  the  sound  should  always  be 
preceded  by  a  bimanual  examination,  and  \ve  can  thus  determine 
the  direction  the  sound  should  take  by  ascertaining  the  exact 
position  of  the  uterus. 

The  sound  may  be  introduced  resting  on  the  finger  or  through 
a  speculum.  It  should  be  introduced  very  gently.  Generally  at 
a  depth  of  about  2  to  5  cm.  (4/5  to  nearly  2  inches)  the  resistance 
of  the  isthmus  is  felt.  Having  passed  this  point,  the  sound  glides 
on  to  the  fundus  which,  normally,  hardly  sensitive,  may  be  pain- 
ful in  certain  inflammatory  conditions. 

Now  attach  a  dressing  forceps  to  the  sound  at  the  level  of 
the  external  os;  then  withdraw  both  dressing  forceps  and  sound, 
and  it  is  easy  to  measure  off  the  depth  of  the  cavity  of  the  uterus. 

Whatever  the  means  employed,  it  is  important  to  observe  pre- 
cautions such  as  the  absolute  asepsis  of  the  hands  and  the  sound, 
the  bimanual  examination  as  a  preliminary  to  ascertain  the 
probable  situation  of  the  uterus,  and  extreme  gentleness  in  the 
manipulations. 

All  acute  inflammations  of  the  vagina  or  cervix  contraindicate 
this  examination. 

The  smallest  suspicion  of  pregnancy  is  an  absolute  contraindi- 
cation. 

By  observing  these  precautions  many  complications  which 
too  often  occur  may  be  averted,  such  as  pain,  colic,  abortion,  per- 
foration, and  septic  complications. 

Indications. — The  introduction  of  the  uterine  sound  may  be 
used  to  determine  the  situation  of  the  uterus,  to  ascertain  the 
existence  of  certain  pathological  conditions  of  the  uterine  cavity 
(structures,  tumors,  etc.),  and  finally  to  measure  the  depth  of  the 
uterus.  It  is  useful  to  introduce  it  as  a  preliminary  to  the  intro- 
duction of  laminaria  tents  in  order  to  find  out  to  what  depth  and 
in  what  direction  these  should  be  entered.  The  normal  depth  is 

5  cm.  to  5  cm.  5  (about  2  to  2  1/5  inches)  in  nullipara,  6  cm.  to 

6  cm.  5  (about  2  2/5  to  2  4/5  inches)  in  multipara,  and  may  be 
as  much  as  8  cm.  (3  1/5  inches)  in  metritis,  8  to  10  cm.  (3  1/5 
to  4  inches)  in  puerperal  subinvolution,  and  15  to  20  cm.  (6  to 
8  inches)  in  a  uterus  containing  fibroids. 


DILATATION  OF  THE  UTERUS  31 

Only  the  metallic  sound  can  give  positive  information  regard- 
ing the  direction  of  the  uterus.  In  a  general  way  this  may  be 
determined  by  the  bimanual  examination,  but  there  are  cases 
where  the  sound  is  a  great  help  to  the  diagnosis,  as,  for  example, 
in  a  uterus  with  a  fibroid  in  the  anterior  wall  simulating  an  ante- 
flexion  of  the  organ  (Figs.  23  and  24). 


FIG.  23. — Uterine  ante-  FIG.  24. — Fibroma  of  anterior 

flexion.  uterine  wall,  simulating,  during 

palpation,  a  uterine  anteflexion 

(see    Fig.   23).      Diagnosis  was 

made  with  the  sound. 

The  sound  enables  us  to  diagnose  a  stricture,  a  partial  or  com- 
plete obliteration  of  the  uterine  cavity,  or  an  intrauterine  tumor 
such  as  fibrous  polyp. 

The  information  we  get,  in  such  a  case  as  we  have  just  cited, 
by  the  use  of  a  sound  is  always  obscure  and  incomplete,  and  only 
intrauterine  palpation  can  give  precise  information. 

We  may  use  the  sound  to  reduce  uterine  displacements,  re- 
volving the  instrument  in  the  uterine  cavity.  This  is  now-a-days 
very  rarely  done. 

In  short,  the  uses  of  the  uterine  sound,  at  one  time  regarded 
as  very  many,  are  now-a-days  very  restricted  and  of  much  less 
importance  than  was  imagined  twenty-five  years  ago.1 

5.  Dilatation  of  the  Uterus. 
There  are  two  varieties  of  dilatation :  rapid  and  slow. 

1.  Rapid  Dilatation. 

Instruments. — Rapid  dilatation  may  be  accomplished  with 
dilators  or  graduated  bougies. 

1  We  differ  very  widely  from  Huguier,  who  in  finishing  his  work  said:  The  uterine 
sound  will  some  day  occupy  a  place  in  the  diagnosis  of  utero-ovarian  troubles  that 
auscultation  and  percussion  occupy  to-day  in  the  diagnosis  of  cardiac  and  chest  com- 
plaints. De  I'hysterometrie  et  du  cathelerisme  ulerin,  Huguier  (P.-C.). 


32  MINOR  GYNECOLOGY 

Varieties  of  uterine  dilators  are  many.  These  are  those  with 
two  or  three  blades,  and  some  of  these  have  a  series  of  transverse 
grooves  on  the  external  surface  of  the  blades,  which  prevents  slip- 


FIG.  25. — Dilator  with  two  blades. 


ping  and  enables  them  to  cope  with  the  elasticity  of  the  uterine 
muscles. 

To  the  dilatation  of  the  cervix,  which  is  obtained  by  these 
dilators,  many  gynecologists  prefer  progressive  dilatation  by  a 


FIG.  26. — Dilator  with  three  blades. 


series  of  cylindrical  bougies,  of  which  the  best  known  type  is 
that  of  Hegar.  They  are  made  of  hardened  gum  or  better  of 
metal,  and  their  length  exclusive  of  the  handle  is  12  to  14  cm. 


FIG.  27. — Dilator  with  transverse  grooving  on  the  external  surface  of  the  blades. 

(about  4  4/5  to  5  3/5  inches).  In  order  to  diminish  their 
number,  wre  recommend  the  double  variety;  that  is,  two 
bougies  of  successive  sizes  united  in  one  by  their  bases  (Fig.  29) . 


FIG.  28. — Hegar's  bougie. 

The  diameter  of  the  bougie  is  1  to  2  mm.  and  increases  succes- 
sively 1  mm.  in  each  bougie. 

Collin  has  recently  produced  cylindro-conical  bougies  which 
are  easier  to  introduce  than  Hegar's. 


DILATATION  OF  THE  UTERUS 


33 


If  a  dilator  or  bougie  is  used,  one  should  be  provided  with  a 
tenaculum  forceps  for  grasping  and  drawing  down  the  cervix 
and  also  with  a  uterine  sound. 

Technic. — The  intestine  is  emptied  the  day  before  by  a  laxa- 
tive or  enema;  the  vagina  is  washed  well  with  soap  and  irrigated 
with  an  antiseptic  solution  such  as  1  in  2000  sublimate. 


FIG.  29. — Hegar's  double  bougie. 

As  the  dilatation  does  not  take  long,  chloride  of  ethyl  is  suffi- 
cient, and  one  should  only  have  recourse  to  chloroform  or  ether 
if  it  is  impossible  to  obtain  sufficient  relaxation  with  the  first 
named. 

In  virgins,  the  index-finger  must  be  gently  introduced  to  avoid 
tearing  the  hymen.  Having  reached  the  cervix  glide  the  tenacu- 


FIG.  30. — Collin's  cylindro-conical  bougie. 

lum  forceps  along  the  finger  and  draw  the  cervix  gently  down 
to  the  vulva.  When  the  hymenal  orifice  is  small,  the  tenaculum 
forceps  may  be  guided  to  the  cervix  by  a  finger  placed  in  the 
rectum.  In  a  married  woman  the  cervix  is  taken  hold  of  after 
pressing  down  the  posterior  vaginal  wall  with  a  Sims'  speculum. 
Having  got  the  cervix  down  to  the  vulva,  determine  with  a 


FIG.  31. — Prepared  laminaria. 

sound  the  direction  of  the  uterine  canal,  and  the  knowledge  thus 
acquired  helps  greatly  in  the  introduction  of  the  dilator. 

Introduce  the  dilator  gently  into  the  os  externum.  If  at  the 
level  of  the  externum  a  resistance  is  felt,  don't  press  on,  but 
slightly  withdraw  the  instrument  and  reintroduce  in  a  direction 
where  no  resistance  is  felt.  It  is  always  dangerous  to  force  a 


34  MINOR   GYNECOLOGY 

dilator  on  because  one  may  perforate  the  posterior  wall  of  an 
anteflexed  uterus. 

Having  introduced  one  instrument,  the  cervical  canal  is  in  a 
sense  dilated,  then  the  instrument  is  rotated  a  little  in  order  to 
dilate  another  part,  and  so  on  until  the  whole  circumference  has 
been  dilated.  It  is  then  \vithdrawn. 

The  next  size  is  introduced  and  so  on  we  continue  until  the 
dilatation  is  equal  to  a  diameter  of  1  cm.  (2/5  inch).  A  greater 
dilatation  may  lead  to  the  laceration  of  the  cervical  canal. 

With  bougies  the  procedure  is  the  same  and  done  with  the 
same  precautions.  The  bougie  is  well  lubricated  and  is  intro- 
duced slowly  without  forcing  and  with  slight  rotatory  movements, 
when  the  pressure  of  the  uterine  walls  is  felt.  The  os  internum 
often  is  very  resistant,  but  it  is  overcome  by  a  gradual  pressure 
on  the  instrument  and  by  modifying  more  or  less  its  direction, 
at  the  same  time  being  very  careful  to  avoid  sudden  pressure 
which  may  lead  to  a  perforation  of  the  uterus. 

Each  bougie  is  left  in  position  an  instant  and  replaced  by  the 
next  number  above  it.  It  is  important  to  introduce  each  instru- 
ment and  not  miss  any  with  a  false  idea  of  saving  time. 

If  a  bougie  cannot  be  introduced,  replace  it  by  the  preceding 
one,  and  leave  it  in  some  seconds.  The  tissues  gradually  accom- 
modate themselves  and  with  a  little  patience  the  recalcitrant 
bougie  will  be  found  to  enter  quite  easily. 

2.  Slow  or  Gradual  Dilatation. 

Instruments  Required. — Formerly  gradual  dilatation  was 
produced  by  the  progressive  accumulation  of  little  tampons  of 
iodoform  wool  bound  together  or  by  the  introduction  of  prepared 
cones  of  sponge,  but  nowr-a-days  use  laminaria  tents,  wrhich  one 
can  obtain  anywhere  already  prepared. 

These  laminaria  tents  are  preserved  in  iodoform  and  ether, 
which  has  the  double  advantage  of  protecting  them  from  the 
hygrometrical  influence  of  the  air,  and  of  slowly  impregnating 
them  with  an  antiseptic.  It  is  important  to  have  a  series  each  of 
different  caliber.  A  great  number  are  sometimes  preserved  in  one 
bottle  but  this  practice  is  disadvantageous  in  that  it  is  difficult 
to  identify  a  laminaria  tent  of  the  size  we  want  and  there  is 


DILATATION  OF  THE  UTERUS 


35 


a   risk  of  infecting  the  others  from  an  instrument  imperfectly 

sterilized. 

The  manufacturers  have  striven  to  prepare  sterilized  lam- 
inaria,  which  are  put  up  in  sealed  tubes  containing  a  little 
vaseline  in  order  to  facilitate  their  introduction.  The  instruments 
required  are  a  speculum,  a  tenaculum  forceps  for  traction,  a  tent 
introducer,  and  some  tampons. 

Technic. — First  determine  the  position  of  the  uterus  by  a 


FIG.  32. — The  laminaria  has  been 
well  introduced  into  the  uterine 
cavity  and  protrudes  from  the  ex- 
ternal os.  It  has  successively  di- 
lated the  cervix  and  body. 


FIG.  33. — The  tent  insufficiently 
introduced  has  succeeded  in  dilating 
merely  the  cervical  canal  to  great 
dimensions. 


bimanual  examination  or  even  by  using  the  uterine  sound.  The 
laminaria  tent,  if  too  stiff,  is  plunged  into  a  hot  solution  of  sub- 
limate and  is  given  the  necessary  inflexion  already  ascertained 
by  the  preliminary  examination. 

Having  done  this  the  speculum  is  put  in  place,  the  tent  seized 


FIG.  34. — The  laminaria  pressed  in  an  anteflexed  uterus,  has,  in  dilating,  perforated 
the  posterior  lip  of  the  cervix. 

in  a  tent  introducer  and  is  gently  passed  into  the  uterine  cavity. 
The  extremity  should  go  well  past  the  internal  os,  and  one  can 
hardly  feel  satisfied  if  a  laminaria  stem  has  penetrated  hardly  3 
or  4  cm.  into  the  uterus. 


36  MINOR  GYNECOLOGY 

It  is  a  mistake  frequently  made  by  beginners,  especially  in 
cases  where  metritis  exists  accompanied  by  enlargement  of  the 
cervical  canal. 

The  laminaria  penetrates  to  a  certain  depth,  and  then  the 
operator  feeling  a  resistance  caused  by  the  os  internum  comes  to 
the  conclusion  that  he  is  dealing  with  a  small  uterus  and  dilates 
only  the  cervical  portion.  It  is  always  of  use  to  ascertain  before- 
hand the  depth  of  the  uterus  by  catheterization  writh  a  soft  bougie. 
When  the  tent  is  in  place,  put  in  two  vaginal  tampons  to  retain  it. 
It  is  of  course  absolutely  essential  for  the  patient  to  remain  in  bed. 

The  introduction  of  the  tent  is  quite  easy  when  its  correct  cali- 
ber and  curve  have  been  ascertained. 

At  times  its  removal  may  present  some  difficulties.  These 
may  arise  pushing  in  the  tent  too  far.  Its  extremity  being  invisi- 
ble, instead  of  seizing  it  directly  and  drawing  it  out  the  tape  is 
pulled  on.  This  should  be  lying  in  the  vagina.  The  tape  breaks 
and  the  tent  remains  imprisoned  in  the  uterus.  The  case  may 
become  more  complicated  when,  for  example,  in  a  strongly  ante- 
flexed  uterus  a  tent  too  forcibly  introduced  into  its  cavity  may 
lead  to  perforation  of  the  posterior  lip  of  the  cervix,  as  a  result 
of  pressure  and  then  comes  to  lie  in  the  vaginal  posterior  fornix. 
Incision  of  the  cervix  may  be  necessary  in  order  to  extract  it. 

Quite  frequently  it  is  the  custom  to  combine  slow  and  rapid 
dilation.  Having  obtained  with  one  or  two  successive  tents,  a 
relative  dilatation  and  a  relaxation  of  the  uterine  tissues,  bougies 
are  introduced  to  obtain  sufficient  dilatation  for  the  insertion  of 
a  finger. 

Indications. — While  in  America  the  rapid  dilatation  is  pre- 
ferred, we  believe  that  in  the  majority  of  cases  the  slow  dilation 
is  the  most  satisfactory. 

It  exposes  the  uterus  less  to  tears  and  perforations,  and  in 
addition  presents  some  definite  advantages. 

Dilatation  by  laminaria  lasts  longer  than  that  obtained  by 
dilators  or  bougies.  In  addition,  it  exercises  an  important  tonic 
action  on  the  uterus,  rendering  the  tissues  more  relaxed  and 
supple.  Rapid  dilatation  should  be  restricted  to  those  cases 
where  dilatation  of  the  uterus  is  a  matter  of  urgency  and  to  com- 
plete the  slow  dilatation  already  obtained  by  tents. 

Uterine  dilatation  may  be  done  with  the  object  simply  of 


INTRAUTERINE  MEDICATION  37 

diagnosis  in  order  to  feel  the  lining  membrane  of  the  uterus,  or 
exceptionally  for  an  eridoscopy.  It  is  mainly  done  for  therapeutic 
purposes.  It  may  in  certain  cases  form  the  basis  of  treatment, 
as,  for  example,  in  strictures  of  the  cervix,  of  uterine  dysmenor- 
rhea,  and  of  sterility.  Generally  it  is  merely  the  preliminary 
but  indispensable  part  of  another  operation  (uterine  curetting, 
removal  of  a  polyp,  etc.). 

6.  Intrauterine  Medication. 

Under  the  generic  term  of  intrauterine  medication  is  included 
lavage  of  the  uterus,  the  application  of  medicated  bougies,  intra- 
uterine cauterizations,  injections,  drainage  of  the  uterus,  vapori- 
zation. 

1.  Intrauterine  Lavage. 

Intrauterine  lavages  enable  us  to  introduce  a  considerable 
current  of  fluid  which,  apart  from  its  antiseptic  action,  which 
is  variable  and  depends  on  the  nature  and  quantity  of  the  anti- 


FIG.  35. — Pinard's  catheter. 

septic  employed,  exercises  also  a  mechanical  action  on  the  con- 
tents of  the  uterine  cavity  (placental  debris,  products  of  secretion) . 
The  operation  may  be  carried  out  (1)  in  the  puerperal  condi- 
tion; (2)  in  the  non-puerperal  condition. 

a.  Intrauterine  Lavage  in  the  Puerperal  State. 

Instruments. — We  require  a  bowl,  a  pair  of  volsellum  or 
tenaculum  forceps,  and  a  cannula.  Immediately  after  the 
accouchement,  when  the  cervix  is  widely  open,  we  may  use  the 
vaginal  cannula,  or  Pinard's  glass  catheter.  At  a  later  stage  it 
will  be  necessary  to  use  a  special  cannula  of  which  various  models 
can  be  obtained.  All  should  fulfill  two  conditions. 


38 


MINOR   GYNECOLOGY 


1.  The  extremity  should  be  slightly  bent  in  order  to  easily 
engage  in  the  normal  uterus  partly  anteflexed. 

2.  The   cannula   should   be   of  the   double-current   variety, 
enabling  entry  and  evacuation  of  fluid  to  proceed  simultaneously. 

In  France,  Budin's  and  Doleris'  instruments  are  generally 


FIG.  36. — Budin's  catheter. 


the  most  used.  Budin's  catheter  is  very  simple.  It  consists 
of  a  tube  for  conveying  fluids  into  the  uterus.  This  tube  is 
grooved  and  the  groove  serves  for  the  evacuation  of  the  fluids. 


FIG.  37. — Doleris'  catheter. 


Doleris'  catheter  consists  of  two  arms,  each  of  which  serves 
as  a  canal  for  the  introduction  of  the  lotion.  It  is  introduced 
closed,  and  once  in  place  one  manipulates  the  small  screw  and 


FIG.  38. — Bozemann's  catheter. 


thus  separates  the  two  arms,  in  this  way  widening  the  cervical 
canal  and  creating  a  way  of  escape  for  the  fluid. 

If  the  uterus  is  small,   we  may  use  Bozemann's  catheter, 
described  in  German  text-books  under  the  name  of  Fritsch.     It 


INTRAUTERINE  MEDICATION  39 

consists  of  two  tubes,  one  contained  in  the  other,  the  smaller 
serving  for  the  introduction  of  fluids  and  the  other  for  their 
evacuation. 


FIG.  39. — The  catheter  having  been  introduced  into  the  cervix,  resistance  at  A  is 
met  with  by  reason  of  the  anteflexion  of  the  uterus. 

Technic. — The    catheter    should    be    introduced    through    a 
speculum  having  first  drawn  down  the  cervix  and  fixed  it. 

It  is  important  to  remember  that  normally  the  uterus  is  ante- 


FIG.  40. — ( Varnier.)  The  upper  two-thirds  of  the  uterus  are  in  a  state  of  contraction. 
The  catheter  meets  with  resistance  at  the  pseudo-sphincter,  AC,  corresponding  to  the 
interior  part  of  the  contracted  zone. 

flexed  and  if  one  pushes  on  straight  ahead  after  having  engaged 
the  catheter  in  the  cervix,  there  is  always  a  risk  of  perforating  the 
posterior  wall  (vide  Fig.  39) .  It  is  important  also  to  remember 


40  MINOR   GYNECOLOGY 

that  after  the  accouchement  and  delivery,  the  uterus  retracts 
unequally ;  while  the  two  upper  thirds  contract  forming  the  globe 
so  well  known  to  all  accoucheurs,  the  inferior  segment  and  the 
cervix  often  thin  out  and  become  soft  and  flabby.  It  will  thus 
be  seen  how  easy  it  is  to  introduce  the  catheter  into  this  lower 
segment  and  not  be  able  to  wash  out  the  upper  two-thirds  at  all 
(Fig.  40). 

It  is  important  to  observe  the  rules  for  the  introduction  of  the 
instrument.  Once  the  catheter  has  engaged  in  the  cavity  of  the 
cervix,  straighten  the  uterus  by  placing  the  left  hand  on  the  hypo- 
gastrium  and  depress  it.  Then  lowrer  the  free  extremity  of  the 
catheter  (as  in  the  diagram)  with  the  right  hand,  and  the  instru- 
ment is  then  gently  introduced  into  the  uterine  cavity  (Fig.  41). 
The  hand  on  the  abdomen  has  reduced  the  anteflexion  of  the 
uterus  and  in  order  to  introduce  the  instrument  into  the  uterine 
cavity,  depress  the  free  extremity  in  the  direction  of  the  arrow. 

If  the  catheter  is  stopped  by  a  uterine  contraction,  press  upon 
the  pseudo-sphincter  thus  created,  with  the  finger,  and  the  catheter 
will  glide  without  difficulty  to  the  fundus  (Fig.  42). 

A  light  pressure  of  water  is  obtained  by  raising  the  douche  can 
30  to  40  cm.  (12* -16")  and  this  suffices  for  flushing  out  the 
uterus.  A  strong  pressure  might  lead  to  the  liquid  pene- 
trating the  uterine  sinuses.  Usually  2  to  4  liters  (70  to  140 
ounces)  are  sufficient.  Finally  give  a  vaginal  injection.  The 
injection  is  repeated  two  or  three  times  in  the  twenty-four  hours. 

The  introduction  of  the  cannula  may  give  rise  to  certain 
difficulties. 

1.  The  cervix  being  very  soft,  it  may  be  impossible  to  distin- 
guish it  from  the  vaginal  walls.     It  will  be  necessary  in  such  a  case 
to  introduce  several  fingers. 

2.  The  cervix  may   be  contracted  and  the  os  closed.     To 
overcome  this  introduce  some  of  Hegar's  dilators. 

3.  The  uterus  may  be  flexed  or  deviated  and  then  we  must 
draw  it  down  with  volsellum  forceps. 

Pinard  and  Varnier  have  used,  in  certain  cases,  continuous 
irrigation.  This  measure  to-day  has  been  abandoned  but  has 
been  of  undoubted  service  in  cases  of  certain  rare  forms  of  pseudo- 
membranous  puerperal  metritis. 

In  order  to  carry  out  continuous  irrigation,  we  must  have  a 


INTRAUTERINE  MEDICATION 


41 


FIG.  41. — The  hand  on  the  abdomen  has  reduced  the  anteflexion.     To  penetrate  the 
cavity  with  the  catheter,  depress  the  full  extremity  in  the  direction  of  the  arrow. 


FIG.  42. — Catheter  in  the  uterus. 


42 


MINOR   GYNECOLOGY 


bed  with  a  spring  mattress.  Place  on  it  two  mattresses,  each 
folded  on  itself  and  separated  so  as  to  leave  a  space  fall  in  the 
middle  of  the  bed.  Cover  each  mattress  with  waterproof  or 
some  impermeable  material  and  so  arrange  the  free  extremities 
of  the  same  that  they  meet  in  the  free  space  in  the  middle  of  the 
bed  and  direct  the  fluid  into  a  receptacle  beneath  it. 

The  reservoir  used  may  be  of  glass  or  of  china,  and  should 
hold  about  20  liters  (700  ounces).  It  is  raised  about  50  cm. 
(1  1/2  feet)  above  the  bed  and  fitted  by  a  rubber  tube  to  the 
catheter  (Fig.  43). 

Complications. — A  series  of  complications  may  occur  during 
an  intrauterine  irrigation. 

1.  Perforation  of  the  Uterus. — This  may  occur  at  the  level  of 
the  inferior  segment,  perhaps,  when  force  is  used  to  overcome 


FIG.  43.  —  Arrangement  of  the  bed  for  continuous  irrigation  (Pinard  and  Varnier). 


the  resistance  or  may  be  at  the  fundus,  if  the  uterus  is  very  septic 
or  if  it  has  lost  its  tonicity. 

2.  Penetration  of  Fluid  into  the  Peritoneum. — To  avoid  this 
always  use  a  light  pressure  of  fluid. 

3.  Introduction  of  Fluid  or  Air  into  the  Veins. — It  is  a  matter 
of  prudence  not  to  flush  out  with  anything  of  a  toxic  nature  during 
uterine  inertia,  but  to  our  mind  it  seems  an  exaggeration  to  fear 
the  use  of  hydrogen  peroxide  during  the  four  or  five  days  imme- 
diately following  an  accouchement,  because  of  the  sinuses  not 
having  completely  closed  and  the  possibility  of  gas  bubbles  enter- 
ing them. 


INTRAUTERINE  MEDICATION  43 

4.  Nervous  Complications. — Such  nervous  complications  as 
shivering,  dyspnea,  cardiac  distress,  syncope,  convulsions,  etc., 
are  still  imperfectly  explained.  If  these  occur,  withdraw  the 
cannula,  lower  the  patient's  head,  and  carry  out  the  treatment  of 
shock. 

Secondary  complications  of  intoxication,  due  to  the  absorption 
of  the  antiseptic  employed,  have  been  cited. 

Indications  and  Contraindications. — Intrauterine  flushing  out 
has  two  main  indications — hemorrhage  and  septic  infection. 

To  combat  hemorrhage,  first  curette  the  uterus  manually  or 
digitally,  and  then  inject  from  3  to  5  liters  (105  to  175  ounces)  of 
sterilized  water  at  48°  Centigrade  (125°  Fahrenheit).  This  will 
produce  a  hemostatic  retraction  of  the  uterus. 

To  combat  septic  infection  accompanied  by  fever  or  retention 
or  fetid  lociiia,  the  irrigation  should  be  carried  out  with  water  to 
which  iodine  has  been  added  (1  or  2  teaspoonfuls  of  French  tinc- 
ture of  iodine  (French  Pharmacopeia  tincture  of  iodine  is  10  per 
cent. ;  B.  P.,  2  1/2  per  cent.)  to  35  ounces  or  1  liter  of  water)  or 
with  permanganate  of  potash  1  to  1000,  or  with  chlorinated  water 
(3  tablespoonfuls  of  the  "liqueur  de  Labarraque"  to  the  liter) 
or  with  hydrogen  peroxide  5  volumes. 

The  intrauterine  injections  are  contraindicated  in  rupture  or 
perforation  of  the  uterus,  even  when  only  suspected  or  if 
a  previous  injection  has  produced  nervous  complications. 

b.  Intrauterine  Lavage  in  the  Non-puerperal  State. 

These  injections  are  generally  carried  out  after  a  preliminary 
dilatation.  A  red  rubber  urethral  catheter  may  then  be  used, 
and  of  course  the  customary  douche-can. 

If  the  uterus  has  not  already  been  dilated,  we  have  recourse  to 
one  of  the  special  instruments  such  as  the  combined  dilator- 
injector  of  Aug.  Reverdin  or  that  of  Jayle.  As  the  arms  of  the 
catheter  are  applied  to  the  right  and  left  sides  of  the  uterus,  these 
parts  are  not  well  irrigated,  so  it  is  as  well  to  have  another  form 
of  the  same  instrument  in  which  the  blades  open  perpendicularly. 

In  this  manner  by  the  alternate  employment  of  both  forms, 
we  can  be  assured  of  a  complete  irrigation  of  the  uterus. 

The  most  varied  solutions  are  employed,  such  as  1  to  2000 


44 


MINOR   GYNECOLOGY 


permanganate  of  potassium;  biniodide  or  sublimate  of  mercury, 
1  to  4000;  argenti  nitras,  1  to  2000;  zinci  chloridi,  1  to  200; 
lysol,  1  to  200,  etc. 

The  most  important  point  to  ascertain  is  that  the  solution 
employed  can  easily  escape  from  the  uterus. 

Complications  may  occur  during  irrigation  similar  to  those 
already  observed  in  the  puerperal  state,  but  they  are  much  rarer. 

2.  Intrauterine  Injections. 

The  intrauterine  injections  have  been  recommended  by  many 
gynecologists  in  the  treatment  of  metritis.  We  may  use  the 


FIG.  44. — A.  Reverdin's  combined  dilating  and  flushing  catheter. 

most  varied  solutions:  Silver  nitrate,  5  to  25  per  1000;  protargol, 
5  to  25  per  1000 ;  chloride  of  zinc,  5  to  50  per  100 ;  copper  sulphate, 
5  to  10  per  100 ;  perchloride  of  iron,  50  to  100 ;  tincture  of  iodine,  20 
to  100;  ichthyol,  pure  or  combined  in  equal  parts  with  glycerine. 


FIG.  45. — Braun's  syringe 

These  irrigations  must  be  made  always  with  a  well  dilated 
cervix  and  only  a  small  quantity  of  solution  introduced  at  a  time. 

To  carry  the  injection  out,  in  Germany,  Braun's  syringe  of 
hardened  rubber  is  used.  One  can  also  use  the  syringe. 

If  a  caustic  solution  is  used,  as  a  preliminary  measure  put  a 
tampon  of  wool  behind  the  cervix  in  order  to  protect  the  vagina. 


INTRAUTERINE  MEDICATION  45 

These  intrauterine  injections  are  not  absolutely  harmless. 
Menge  has  collected  thirty  instances  of  death  after  the  use  of 
Braun's  syringe.  Deaths  have  occurred  after  its  use  in  doctors' 
consulting-rooms  or  even  in  the  street,  when  the  patient  is  return- 
ing home.  It  can  be  understood  what  a  commotion  such  acci- 
dents would  cause,  following  on  a  treatment  considered  by  the 
family  and  friends  as  absolutely  simple — used  only  to  give  a 
little  relief. 

These  accidents  are  occasioned  by  the  penetration  of  the  solu- 
tion into  the  tubes  and  then  into  the  peritoneal  cavity  and  this 
penetration  has  been  experimentally  demonstrated  by  such  men 
as  Doderlein,  Zweifel  and  Menge.1  There  is,  therefore, '  good 
reason  to  abandon  these  injections. 

3.  Application  of  Medicated  Bougies  and  of  Caustics  to  the  Uterine 

Cavity. 

Medicated  bougies  or  pencils  which  are  introduced  into  the 
uterine  cavity  are  formed  of  a  paste-like  material,  quite  firm  at 
ordinary  temperature,  but  which  softens  in  the  uterine  cavity  and 
then  is  liberated  from  this  pasty  material  the  active  ingredient. 

One  of  the  most  frequently  employed  is  the  iodoform  pencil 
or  bougie: 

ty. — Iodoform,  20  grams =5  drams. 

Gum  arabic, 
Glycerine, 


Amidon,  aa 


For  10  pencils. 


2  grams  =  30  grains. 


Pencils  of  ichthyol  are  frequently  used. 

Caustic  Pencils. — One  of  the  most  frequently  used  forms  is 
that  of  Dumontpallier  contained  in  Canquoin's  paste  (chloride  of 
zinc  1,  rye  flour  2).  The  pencil  weighs  1  gram  (15  grains)  and  is 
surrounded  by  a  piece  of  tin  in  the  portion  which  would  lie  at  the 

1  Doderlein,  before  dcing  vaginal  hysterectomies,  made  a  series  of  intrauterine  injec- 
tions with  coloring  agents  and  determined  therewith  the  immediate  presence  of  these 
solutions  in  the  tubes  and  peritoneal  cavity.  An  objection  was  raised  to  this,  viz.,  that 
this  penetration  was  due  to  manipulations  of  the  uterus  during  the  course  of  the  opera- 
tion. However,  Zweifel  and  Menge  have  observed  the  same  occurrences  in  abdominal 
sections  and  have  seen  the  colored  solution  appear  at  the  opening  of  the  tubes  without 
any  manipulation  of  the  uterus  at  all. 


46  MINOR   GYNECOLOGY 

internal  os.  It  may  be  introduced  into  the  uterus  and  allowed 
to  remain  there.  During  the  month  following  the  cauterization, 
it  is  important  to  pass  a  catheter  with  an  olive  tip,  frequently, 
in  order  to  avoid  the  production  of  atresia.  Numerous  complica- 
tions such  as  stenosis,  obliteration  with  amenorrhea  and  hemato- 
metra,  dysmenorrhea,  and  troubles  in  the  adnexa  have  caused 
the  almost  complete  abandoning  of  these  pencils,  which  enjoyed 
for  some  time  an  unmerited  vogue. 

Silver  nitrate  pencils  are  introduced  and  left  in  the  uterus; 
also  those  of  corrosive  sublimate  (corrosive  sublimate  1,  talc 
powder  0.5,  tragacanth  gum  0.3,  water  and  glycerine,  q.  s.). 

All  these  caustics,  in  which  one  is  unable  to  control  the  action, 
should  be  abandoned. 

It  is  not  the  same  with  Filhos  bougies  which  are  applied  to  the 
treatment  of  cervical  catarrh.  The  employment  of  these  pencils 
consisting  of  Vienna  paste  solidified  and  placed  in  leaden  tubes, 
has  been  popularized  quite  recently  by  L.  G.  Richelot. 

A  slender  tampon  of  absorbent  wool  is  placed  in  the  posterior 
fornix;  the  leaden  tube  is  cut  with  a  knife  and  the  caustic  is 
forced  out  about  half  a  centimeter  (about  1/5  of  an  inch).  Hold- 
ing the  closed  end  of  the  tube  in  a  pair  of  forceps,  the  caustic  is 
applied  for  some  time  to  each  part  of  the  cervix,  waiting  until  the 
mucous  membrane  thus  attacked  becomes  blackened  and  begins 
to  bleed.  It  is  applied  to  the  w7hole  cervix  and  particularly  to 
those  parts,  here  and  there,  where  the  trouble  is  most  aggravated. 
From  time  to  time,  wipe  the  end  of  the  caustic  and  lift  up  the 
pulpy  substance  which  covers  over  the  cervix  and  continue  until 
the  eschar  formed  is  black  and  everywhere  well  formed. 

This  operation  lasts  from  3  to  5  minutes  and  afterward  an 
iodoformed  tampon  is  placed  against  the  cervix. 

Cauterization  is  either  slightly  painful  or  painless ;  in  any  case 
pain  ceases  after  the  third  or  fourth  application.  The  patient 
can  return  to  her  home,  but  she  should  rest  in  the  extended  posi- 
tion, if  possible,  all  day  long.  On  the  following  day  she  should 
take  out  the  tampon  and  make  one  or  two  injections  daily  of 
boiled  water. 

The  cauterizations  are  renewed  every  five  or  seven  days, 
always  waiting  until  the  eschar  has  completely  separated. 

The  number  of  cauterizations  varies  from  eight  to  twelve. 


DRAINAGE  OF  THE  UTERUS  47 

Between  the  little  operations  if  the  area  dealt  with  has  cicatrized 
completely,  the  volume  of  the  cervix  is  reduced  and  its  form 
satisfactory. 

Probes  for  Applying  Caustics. — These  are  numerous  and  of 
every  imaginable  form.  It  would  appear  to  us  that  the  best  is 
to  use  a  metallic  stem  with  a  flexible  end  which  is  spirally  grooved. 
As  a  result  of  this  flexibility  this  probe  can  follow  the  deviations 
of  the  uterine  canal  and  reach  the  f undus,  without  need  for  a 
preliminary  dilatation. 

Around  the  probe  a  thin  wisp  of  wool  is  rolled,  being  careful 
to  use  only  one  piece,  so  as  to  be  able  to  withdraw  the  whole  in 
its  entirety.  The  wool  is  left  in  the  form  of  a  tuft  at  the  end  of 
the  probe  in  such  a  manner  that  the  liquid  caustic,  being  expressed 


FIG.  46. — Probe  with  flexible  extremity. 

by  pressure  against  the  fundus  of  the  uterus,  can  flow  over  the 
whole  length  of  the  mucous  membrane.  The  wool  rolled  around 
the  stem  of  the  probe  should  extend  down  low  enough  so  that  it 
lies  below  the  vaginal  portion  of  the  cervix,  thus  enabling  us  to 
seize  it  with  a  pair  of  forceps  and  to  be  certain  of  removing  both 
probe  and  wool  together. 

Chloride  of  zinc  may  be  used  in  50  to  100,  nitrate  of  silver 
50  to  100,  tincture  of  iodine,  perchloride  of  iron,  and  formalin 
25  to  100. 

It  is  absolutely  necessary  for  each  cauterization  to  pass  the 
probe  gently  around  two  or  three  times.  As  a  dressing,  place 
a  tampon  of  iodoform  against  the  cervix.  Don't  practice  cauteri- 
zation too  often,  and  let  eight  or  ten  days  elapse  between  each  one. 

7.  Drainage  of  the  Uterus. 

The  placing  of  a  drain  in  the  uterus  is  done  in  order  to 
keep  the  cavity  well  open  in  order  to  facilitate  the  discharge  of 
secretions. 

For  this  purpose  \ve  use  glass  tubes  pierced  with  small  holes 
(Fehling),  metallic  tubes  (Lefour),  metallic  drains  (Petit),  etc. 


48 


MINOR   GYNECOLOGY 


The  fixation  of  these  drainage  apparatus  in  the  uterus  is 
secured  by  passing  silk  or  horsehair  stitches  through  the  lips  of 
the  cervix. 

These  measures  of  permanent  drainage  are  contraindicated 
whenever  there  exists  the  least  inflammatory  state  of  the  adnexa. 
It  appears  to  us  to  be  hardly  necessary  to  state  the  indications  as 
we  have  never  had  recourse  to  it.  We  have  only  had  occasion  to 
use  this  drainage  after  intrauterine  intervention  and  then  we  used 
a  simple  rubber  drain  which  was  held  in  place  by  a  tampon  placed 
against  the  external  os. 

8.  Atmokausis. 

Under  the  name  of  atmokausis  (di^o?,  vapor)  we  wish  to 
designate  a  special  method  of  physical  cauterization  in  which  the 


FIG.  47.— Lefour's  tube.  FIG.  48.— Petit's  drain. 

cauterizing  agent  is  simply  steam. 

First  used  in  Russia  by  Sneguiref ,  atmokausis  has  been  prin- 
cipally employed  in  Germany  where  it  has  been  the  subject  of 
numerous  works  principally  by  such  men  as  Pincus  and  Duhrsen.1 

Instruments  Required. — Sneguiref  simply  used  a  boiler  and  a 
reservoir  for  the  steam,  and  a  rubber  and  a  metal  tube.  Duhrsen 

1  L.  Pincus,  Atmokausis  und  Zestokausis,  Second  Edition,  Wiesbaden,  1906. 


ATMOKAUSIS 


49 


introduced  into  the  uterus  two  concentric  tubes,  of  which  the 
external  was  a  bad  conductor  of  heat  in  order  to  avoid  burning 
the  cervix. 

Pincus'  apparatus  is  the  most  used.  The  generator  is  a 
small  boiler  capable  of  a  pressure  of  2  1/2  atmospheres. 
Its  cubic  contents  are  600  c.c.  and  it  is  cylindrical  in 
shape.  Attached  to  the  lid  of  the  boiler  is  a  graduated 
thermometer  "capable  of  registering  up  to  120°  C. ;  second, 
a  safety  valve  which  releases  the  steam  at  115°;  third,  a 


FIG.  49. — Pincus'  apparatus. 

metal  tube  raised  to  a  certain  height  in  order  to  avoid  the  pro- 
jection of  water  into  the  rubber  tube  to  which  it  is  attached. 
This  rubber  tube  is  specially  strong  and  is  strengthened  by  a 
woven  band  around  it.  It  is  connected  by  a  tube  with  the 
steam  pipe.  It  is  75  cm.  (30  inches)  to  1  meter  (39  inches) 
long  and  terminates  in  a  stop-cock  with  three  valves,  which 
may  close  off  the  boiler  and  permit  the  steam  to  escape  or  to 
enter  the  uterine  catheter. 

This  catheter  consists  of  two  tubes,  one  contained  in  the 
other.  The  internal  is  pierced  with  small  openings  along  its 
whole  length  of  3  cm.  (l|")  and  it  conducts  the  steam.  The 


50  MINOR   GYNECOLOGY 

• 

external  tube,  closed  on  its  convex  side,  is  pierced  in  front 
by  three  elongated  windows  and  through  these  the  steam  escapes. 
Place  on  the  end  of  the  uterine  catheter  tips  of  various  forms 
to  accommodate  to  the  length  and  curve  of  the  uterus. 

A  cover  protects  the  cervix. 

Technic. — Anesthesia  is  not  required  for  atmokausis.  The 
cervical  canal  should,  as  a  preliminary,  be  dilated  by  laminaria 
tents  or  Hegar's  dilators. 

Having  introduced  the  speculum,  seize  the  cervix  with  a 
volsellum  forceps  and  introduce  the  catheter  into  the  uterus. 
Push  it  on  as  far  as  the  fundus  and  then  draw  it  back  a  little 
so  that  the  extremity  is  free.  Then  allow  the  steam  to  pass 
through. 

If  a  superficial  destruction  of  the  mucous  membrane  is  desired, 
such  as  would  be  the  case  in  \vomen  during  the  period  of  sexual 
activity,  Pincus  advocates  passing  a  jet  of  steam  at  115°  C. 
during  a  very  short  time,  say  5  to  15  seconds. 

After  the  menopause,  in  a  case  where  the  whole  of  the  mucous 
membrane  should  be  destroyed,  steam  at  105°  C.  is  used,  but 
it  is  allowed  to  pass  during  a  longer  period  of  time,  that  is  2 
to  3  minutes. 

There  is  an  immediate  discharge  of  a  dark  fluid  \vhich  reminds 
one  of  strong  bouillon.  For  some  days  following  this  operation 
the  necrosed  part  becomes  detached  and  a  sero-sanguineous  dis- 
charge takes  place.  It  is  not  at  all  rare  to  see  an  elevated  tem- 
perature similar  to  that  seen  after  an  accouchement  and  caused  by 
retained  lochia.  In  event  of  a  rise  in  temperature  flush  out  the 
uterus  with  a  double  current  catheter. 

The  regeneration  of  the  mucous  membrane  occurs  in  the 
same  manner  as  after  a  curetting  if  some  isles  of  mucous  mem- 
brane have  been  left. 

Complications. — Complications  have  been  cited  as  a  result  of 
intrauterine  vaporization,  some  immediate  and  spme  consecutive. 

The  immediate  complications  are  burns  to  the  vagina,  to  the 
vulva,  and  to  the  external  surface  of  the  cervix.  There  is  less 
risk  of  producing  these  with  Pincus'  apparatus  than  w7ith  that 
of  Duhrsen,  which  has  no  rubber  tube  for  the  evacuation  of 
the  steam  and  allows  the  steam  to  go  out  alongside  the  catheter 
in  the  cervical  canal. 


ATMOKAUSIS  51 

The  accidents  which  occur  later  are  the  stricture  of  the  cervix, 
the  complete  or  partial  obliteration  of  the  uterine  cavity,  death 
by  perforation  of  the  uterus,1  and  inflammation  extending  to 
the  diseased  adnexa. 

Indications. — Atmokausis  has  been  employed  in  the  treatment 
of  hemorrhagic  metritis,  septic  puerperal  metritis,  fibromas  and 
menopause  hemorrhages.  It  has  also  been  used  to  cause  a  retro- 
gression of  an  incompletely  involuted  uterus,  to  treat  subacute 
gonorrhea,  etc.  Pincus  advocates  it  for  disinfecting  retained 
placenta. 

There  is  a  manifest  exaggeration  in  the  indications  of  the 
method;  it  is  quite  certain  that  when  we. are  faced  with  a  pla- 
cental  retention  or  a  decidual  hemorrhagic  metritis,  the  indication 
is  to  empty  the  uterus. 

Atmokausis  appears  to  us  to  have  the  great  inconvenience  of 
being  a  blind  method,  whose  action  is  with  difficulty  regulated.2 
Doderlein  and  Kronig  reproach  the  method  very  deservedly, 
because  it  does  not  act  uniformly  on  the  whole  of  the  uterine 
cavity;  their  researches  have  showrn  that  while  at  the  level  of  the 
point  corresponding  to  the  opening  of  the  tube  a  deep  eschar 
is  produced,  the  mucous  membrane  in  other  parts  is  macro- 
scopically  and  microscopically  intact.  We  believe  that  it  is  a 
method  which  is  only  allowed  to  exist,  owing  to  the  contra- 
indications of  other  forms  of  intrauterine  treatment.  Doderlein 
and  Kronig  think  that  one  should  rightly  try  it  in  hemorrhagic 
endometritis  which  curetting  has  not  cured,  in  hemorrhages 
occurring  in  leucemia,  where  intervention  of  a  larger  order  is 
dangerous,  in  those  of  diabetes,  hemophilia,  Werdolf's  disease, 
or  where  there  is  a  contraindication  to  anesthesia  and  in  hemor- 
rhages occurring  at  the  menopause  wrhen  there  is  certainly  no 
neoplasm  present. 

1  In  a  case  of  Van  der  Velde  and  Treub,  Pincus'  apparatus  was  used.     The  steam  at 
105°  C.  had  been  passing  about  1  minute.     Peritonitis  supervened  as  the  result  of  a  perfora- 
tion of  the  fundus.     There  was  found  to  be  total  necrosis  of  the  mucous  membrane  and 
in  certain  places  superficial  necrosis  of  the  muscle. 

2  Flatau  has  made  a  series  of  examinations  of  uteri  freshly  removed.     He  states:  (1) 
That  the  temperature  indicated  by  a  thermometer  plunged  through  the  uterine  wall 
into  its  cavity  varies  between  70  and  80°  C.  when  the  thermometer  on  the  generator  marks 
105  to  110°.    (2)  That  the  Jesuits  are  extremely  variable,  the  mucous  membranes  being  at 
times  hardly  touched,  sometimes  entirely  destroyed,  the  intensity  of  the  cauterization  de- 
pending much  less  on  the  duration  of  the  steam  vaporization  than  the  size  of  the  uterine 
cavity,  of  the  anatomical  variety  of  the  metritis,  of  the  variable  contents  (presence  or  ab- 
sence  of  blood),  of  the  uterine  cavity.     (Flatau,  Monatschr.f.  Geb.  u.  Gyn.,  1899,  T.  II, 
p.  337.) 


52 


MINOR   GYNECOLOGY 


Zestokausis. — Under  this  name  Pincus  describes  a  method  of  cauter- 
ization by  dry  heat.  The  instrument  is  introduced  into  the  uterus  and  the 
interior  only  is  heated  by  a  circulation  of  steam  which  does  not  come  into 
actual  contact  itself  with  the  uterine  tissue.  It  is  employed  in  dysmenor- 
rhea  and  incomplete  involution  of  the  uterus.  The  results  published  are 
still  too  few  for  us  to  give  any  opinion  on  this  form  of  treatment. 


9.  Bier's  Method. 

The  production  of  local  hyperemia  which  constitutes  the 
characteristic  of  Bier's  method  for  the  treatment  of  inflamma- 
tion is  carried  out  in  three  ways,  viz.,  the  application  above  the 


FIG.  50. — Rudolph's  apparatus  for  hot-air  injections. 

diseased  part  of   a  constricting  band,   by  the  action  of    heat, 
and  by  aspiration. 

The  last  two  procedures  have  been  applied  to  uterine  troubles, 
in  particular  to  inflammation  of  the  cervix. 


FIG.  51. — Eversmann's  cupping  apparatus. 


In  order  to  produce  the  thermic  action,  J.  Rudolph1  has 
produced  an  apparatus  like  a  bent  trumpet.  The  expanded 
end  consists  of  metal  and  it  is  attached  by  a  joint  of  amianthus 
to  the  tube  portion  which  consists  of  wood  (Fig.  50). 

The  terminal  part  in  wood  is  divided  by  a  septum  into  two 

1  Rudolph  (J.),  Die  Bier'sche    Staaung  in  der  gynakologischen  Praxis.     Zentr.-Bl. 
f.  Gyn.,  Leipzig,  1905,  p.  1185. 


PESSARIES  53 

compartments.  The  heat  gets  to  the  cervix  through  the  lower 
part  a,  then  flows  into  the  upper  chamber  b  and  goes  out  through 
a  special  orifice  at  c. 

If  the  cupping  apparatus  is  used  the  best  is  that  of  Evers- 
mann,1  consisting  of  a  glass  cylinder  closed  at  one  end.  This  is 
applied  to  the  cervix  and  by  means  of  a  rubber  tube  and  stop- 
cock attached  near  its  extremity  air  can  be  exhausted  from  it. 

10.  Pessaries. 

Pessaries  are  instruments  designed  to  keep  the  uterus  in  its 
natural  situation. 

History. — In  ancient  times  pessaries  were  employed  to  remedy 
prolapse  of  the  uterus.  In  place  of  the  apples  and  oranges  which 
were  used'  in  the  middle  ages  by  women  to  prevent  prolapse, 
appropriate  apparatus  was  introduced  to  remedy  this  con- 
dition. In  a  book  written  by  A.  Pare  we  find  a  description 
of  pessaries  and  their  method  of  employment.  Since  the 
study  of  uterine  deviations  has  begun,  Neugebauer  has  been 
able  to  collect  400  different  forms.  Since  the  great  exten- 
sion of  operative  gynecology,  pessaries  have  been  almost  com- 
pletely given  up.  Some  gynecologists,  Kustner  in  Germany 
and  Bantock  in  England,  have  protested  recently  against  this 
abandoning  of  pessaries.  In  actual  practice,  doctors  in  France 
hardly  ever  advise  the  use  of  pessaries  and  if  they  do  they  content 
themselves  with  advising  the  patient  to  buy  a  ring  at  an  instru- 
ment shop.  If  she  is  advised  to  have  a  little  operative  inter- 
vention, she  sometimes  goes  directly  to  the  instrument  maker's 
who  furnishes  her  with  an  apparatus  the  dimensions  of  which 
are  such  as  to  render  it  useless  and  the  application  is  probably 
improperly  made,  if  she  is  not  taught  how.  It  is  quite  evident 
that  the  doctor  is  wrong  in  being  so  disinterested  in  the  pessary, 
and,  although  he  should  not  attach  so  much  importance  to  it 
as  was  the  custom  long  ago,  still  he  should  act  as  an  intermediary 
between  the  instrument  maker  and  the  patient — a  state  of  affairs 
which  would  assist  the  woman  greatly. 

The  Various  Types  of  Pessaries. — There  are  three  great  classes 
of  pessaries: 

1  Eversmann  (J.),  Ibidem,  p.  1467. 


54 


MINOR   GYNECOLOGY 


1.  The  vagino-abdominal  pessary  is  applied   in   the  vagina 
and  is  fixed  to  an  external  part  which  is  supported  from  the 
abdomen. 

2.  The  vaginal  pessaries  which  are  entirely  included  in  the 


vagina. 


3.  Intrauterine  pessaries   which   penetrate   into   the   uterine 
cavity. 


FIG.  52. — Borgnet's  pessary. 

We  wrill  not  discuss  the  last  variety  as  so  many  complications 
may  be  set  up  by  their  use  that  they  have  been  abandoned. 

Vagino-abdominal  Pessaries. 

These  pessaries,  sometimes  called  hysterophores,  are  used 
to  support  the  uterus  in  prolapse. 

They  consist  of  a  pad,  a  ring,  a  sort  of  ampulla  which  supports 


FIG.  53. — Insufflating  bag.  FIG.  54. — Gaull's  air  pessary. 

the  cervix  and  which  is  fixed  to  the  abdominal  belt  of  various 
forms. 


Vaginal  Pessaries. 

Their  variety  is  considerable.     Among  those  most  employed 
we  will  cite  that  of  Dumontpallier,  those  of  Thomas,  Hodge, 


PESSARIES  55 

Smith  and  Schultze.  The  last  named  has  made  a  profound 
study  of  uterine  deviations  and  their  treatment.  Patients  still 
sometimes  use,  most  often  on  the  advice  of  their  doctor,  the 
india-rubber  sphere,  which  is  blown  up  when  once  in  place. 
This  pessary,  like  all  those  of  soft  rubber,  has  the  disadvantage 
of  easily  altering  its  shape  (Figs.  53  and  54). 

Dumontpallier's  Pessary.—  It  consists  of  a  sort  of  watch  spring 
covered  over  "with  rubber  (Fig.  55). 


FIG.  55.  FIG.  56.  FIG.  57. 

Hodge's  Pessary. — This  pessary  has  the  form  of  a  rectangle, 

with  the  angles  rounded  and  is  doubly  curved  (Figs.  56  and  57). 

Gaillard   Thomas'1  Pessary. — It  has  the  shape  of  a  Hodge 


FIG.  58.  FIG.  59.  FIG.  60. 


pessary  in  which  the  posterior  arc  is  markedly  thickened  (Figs. 
58  and  59). 

Albert  Smith's  Pessary. — Also  the  same  form  as  the  Hodge 
except  that  the  inferior  part  is  narrowed  (Figs.  60  and  61). 

These  three  varieties  of  pessaries  act  indirectly  on  the  cervix 
by  the  tension  of  the  surrounding  parts. 

Schnitzels  Figure-of-8  Pessary. — The  upper  loop  of  the  8  is 
smaller  than  the  other.  It  embraces  the  cervix  but  not  too 


56 


MINOR   GYNECOLOGY 


tightly,  while  the  lower  loop,  proportioned  correctly  to  the 
vaginal  capacity,  is  held  by  the  vulvar  orifice  which  prevents 
its  expulsion  forward.  This  pessary  has  a  direct  action  on 
the  uterus.  Grasping  the  cervix  it  forces  it  backward  (Figs.  62 
and  63). 

Schultze's  Sledge-formed  Pessary. — The  sledge-formed  pessary 
consists  of  a  posterior  portion  which  embraces  the  cervix  and  a 


FIG.  61. 


FIG.  62. 


FIG.  63. 


widened  anterior  portion  which  fits  anteriorly  into  the  anterior 
fornix  (Figs.  64  and  65). 

These  different  models  of  pessaries  are  generally  made 
beforehand  in  hardened  india-rubber.  It  is  much  better  to 
model  the  pessary  on  the  conformation  of  the  vagina.  Marion 


FIG.  64. 


FIG.  65. 


Sims  used  to  do  this  and  made  his  with  rings  consisting  of  an 
alloy  of  tin  and  lead.  Schultze  prefers  rings  of  celluloid  which 
soften  easily  in  warm  water  and  then  preserve  the  form  given 
them.  They  have  the  advantage  of  being  light,  smooth,  and 
their  polish  is  not  altered  by  the  vaginal  secretions. 

Mode  of  Introduction  and  Details  to  Observe. — Whatever  be 
the  form  of  pessary  used,  commence  by  replacing  the  uterus. 
The  pessary  used  should  be  large  enough  to  be  in  contact  with 


PESSARIES  57 

the  vaginal  walls,  but  not  too  large  so  that  they  are  distended. 
It  is,  as  a  preliminary,  allowed  to  rest  some  time  in  hot  water 
vaselined  well  and  introduced. 

Dumontpallier's  pessary  is  the  simplest  to  introduce.  One 
has  only  to  bend  it  between  the  thumb  and  first  finger  and 
then  introduce  the  upper  part  into  the  posterior  fornix.  Then 
relax  hold  of  it  and  it  will  spontaneously  take  its  position.  The 
pessary  will  oe  found  lying  at  the  extremity  of  the  vagina  com- 
pletely surrounding  the  cervix  like  a  crown.  If  it  does  not 
spontaneously  find  the  correct  position,  it  may  be  easily  manipu- 
lated with  the  finger. 

Both  fornices  being  distended,  this  pessary  immobilizes  the 
uterus  and  maintains  it  in  a  good  direction,  at  the  same  time 
preventing  invagination  of  the  vagina  and  preventing  prolapse. 

In  orde'r  to  make  it  very  efficacious  in  its  action  the  vagina 
must  be  sufficiently  distended;  also  it  is  necessary  to  choose 
a  ring  whose  dimensions  are  proportioned  to  the  canal. 

In  order  to  introduce  Hodge's  pessary  it  should  be  presented, 
so  to  speak,  in  the  antero-posterior  plane  which  corresponds  to 
the  greatest  diameter  of  the  vulva.  The  ring  having  passed 
the  vulvar  orifice  one  gives  the  instrument  a  turn  through  a 
quarter  of  its  circumference,  and  then  carries  it  on  till  its  annular 
extremity  lies  deeply  in  the  posterior  fornix.  The  inferior 
extremity  should  rest  a  little  below  the  urinary  meatus. 

The  abdominal  pressure  tends  to  force  the  pessary  into  the 
horizontal  plane ;  under  these  conditions,  the  posterior  extremity, 
falling  down  somewhat,  stretches  the  posterior  vaginal  wall  and 
leads  to  the  drawing  back  of  the  cervix  and  the  levering  forward 
of  the  body  of  the  uterus. 

The  rigid  pessaries  when  of  correct  dimensions  should  not 
distend  the  vaginal  walls  excessively;  it  is  a  good  plan  to  be  able 
to  pass  one's  fingers  between  them  and  the  vaginal  wall  in  order 
to  avoid  unpleasant  complications. 

Once  in  place  make  certain  that  the  pessary  retains  its 
position  when  the  patient  stands  up. 

Then  ask  the  patient  to  go  through  a  series  of  movements, 
bending  forward  and  backward,  sitting  down  in  a  crouching 
position,  etc.,  so  as  to  be  sure  of  the  pessary  remaining  in 
position. 


58  MINOR  GYNECOLOGY 

After  several  days,  reexamine  the  patient  to  see  if  the  pessary 
is  still  in  good  position  and  does  not  cause  any  unpleasant  or 
painful  sensations.  The  pessary  should  only  give  evidence  of 
its  presence  by  the  relief  it  affords. 

Thus,  as  the  patient  does  not  feel  the  pessary,  always  warn 
her  of  its  presence,  and  don't  allowr  her  to  forget  its  existence 
and  leave  it  indefinitely  in  place  at  the  risk  of  leading  to  ulcera- 
tion  and  even  perforation  of  the  neighboring  cavities. 

Daily  injections  of  boiled  water  with  perhaps,  if  necessary, 
the  addition  of  a  little  carbolic  acid,  lysol,  permanganate  of 
potash,  are  useful  to  keep  the  pessary  clean  and  to  prevent  the 
accumulation  of  spermatic  fluid  and  secretions  of  the  cervix 
upon  it. 

Dumontpallier's  pessary  should  be  taken  out  every  day, 
washed  and  replaced  by  the  patient,  but  this  cannot  be  done 
with  other  varieties  of  pessaries  which  have  to  be  introduced 
by  the  doctor. 

The  great  majority  do  not  prevent  coitus;  their  presence  is 
not  even  suspected  by  the  unwarned  spouse. 

The  duration  of  leaving  a  pessary  in  place  depends  upon 
the  substance  of  which  it  is  made.  Rubber  pessaries  not  vul- 
canized become  altered  soon. 

As  a  general  rule  it  is  useful  to  take  them  out  from  time  to 
time,  every  one  or  two  months,  and  examine  the  vagina  for 
erosions  of  the  mucous  membrane,  which  may  occur  without 
the  patient  being  aware  of  it. 

Complications. — A  series  of  complications  may  occur  varying 
from  the  simple  calcareous  incrustation  of  the  pessary  to  the 
formation  of  vesico-  or  recto-vaginal  fistulae,  resulting  from 
inflammation  and  ulceration  of  the  vagina.  Cases  have  been 
cited  also  of  inflammatory  periuterine  swellings,  and  also 
strictures  preventing  the  withdrawal  of  the  pessary,  etc.1 

All  these  complications  can  easily  be  avoided  if  one  takes 
the  precautions  we  have  cited  above. 

Nous  will  again  assert  that  we  reject  absolutely  the  pessaries 

1  Neugebauer  has  collected  364  cases  of  complication  produced  by  pessaries,  42  vesico- 
vaginal  fistulae,  37  recto- vaginal  fistulas,  13  combined  vesico-  and  recto- vaginal  fistulae, 
2  utero-vaginal  fistulae,  1  utero-vesico-vaginal  fistula,  3  perforations  of  the  urethra,  1 
perforation  of  the  small  intestine,  4  perforations  of  pouch  of  Douglas,  and  11  pene- 
trations of  vaginal  pessaries  into  the  uterus. 


PESSARIES  59 

with  an  intrauterine  stem.  Winged  pessaries  of  the  type  of 
Zwank  are  still  greatly  employed  in  Germany,  but  happily  have 
not  yet  been  used  in  France.  They  are  very  frequently  the 
starting-point  of  ulceration,  because  the  patients  do  not  take 
them  out  at  night  as  they  should  and  the  continual  pressure 
of  the  wings  rapidly  ulcerates  the  mucous  membrane. 

Unvulcanized  rubber  pessaries  become  encrusted  with  great 
ease;  to  avoid'this  take  them  out  and  wash  them  very  frequently. 

As  for  other  pessaries,  if  the  pressure  they  exercise  on  the 
vaginal  wall  is  not  too  considerable  and  if  sufficient  cleanliness 
is  observed,  complications  are  rarely  observed. 

Indications. — In  principle  all  cases  of  prolapse  should  be 
operated  upon  if  there  are  no  contraindications  in  the  general 
state  (diabetes,  obesity,  cardiac  or  pulmonary  affections).  In 
practice  a  great  number  of  elderly  women,  to  whom  one  has 
advised  surgical  intervention,  promptly  go  to  an  instrument 
maker  to  buy  a  pessary  with  an  external  support,  which  pro- 
cures the  required  relief.  If  one  talks  writh  a  pessary  maker 
one  can  learn  of  the  enormous  number  of  such  apparatus  he 
sells  apart  from  those  ordered  by  medical  men,  and  also  of  the 
number  of  women  who  treat  themselves  quite  independently  of 
medical  advice. 

If  one  finds  a  .case  of  complete  prolapse  of  the  uterus  due 
to  one  of  these  vagino-abdominal  pessaries,  one  can  give  relief 
to  the  sufferers  by  applying  a  pessary  which  supports  the 
uterus  and  at  the  same  time  corrects  the  deviation,  because  it  is 
most  frequently  retrodeviated  as  well  as  prolapsed.  For  this 
purpose  Schultze's  sledge  pessary  is  the  instrument  of  choice. 

Apart  from  these  troubles  caused  by  a  retrodeviation,  the 
pessary  can  also  render  service  if  there  are  not  any  concomitant 
inflammatory  phenomena,  if  the  perineum  is  sufficient  to  insure 
its  stability  and  if  the  vagina  has  not  undergone  the  alterations 
of  senility,  such  as  rigidity  and  atrophy,  which  expose  it  to 
ulceration  and  the  conical  form  which  does  not  permit  the 
application  of  the  instrument. 

With  the  exception  of  these  cases  a  pessary,  well  fitted  and 
applied,  may  lead  not  only  to  redressing  the  deviation  but  also 
to  the  cure  of  the  condition.  This  is  the  opinion  of  Kustner  and 
others  who  have  carefully  studied  the  question.  Gradually  the 


60  MINOR   GYNECOLOGY 

means  of  fixation  of  uterus  become  more  and  more  strengthened, 
and  the  uterus  can  maintain  itself  in  a  good  position.  The  suc- 
cesses which  our  operative  measures  have  secured,  in  that  a 
rapid  cure  is  accorded  to  the  woman  who  earns  her  living, 
should  not  make  us  forsake  the  orthopedic  treatment  in  women 
of  comfortable  circumstances. 

As  a  general  rule,  according  to  Kustner,  the  pessary  must 
be  worn  from  several  months  to  several  years  until  the  uterus 
of  itself  occupies  the  normal  position.  If  a  pregnancy  occurs  take 
the  pessary  out  at  the  fifth  month. 

Hodge's  pessary  or  Smith's  suffices  in  a  great  many  cases; 
if  a  marked  relaxation  of  the  posterior  fornix  is  diagnosed, 
Thomas'  pessary  is  preferable. 

In  principle,  Schultze's  pessary  is  the  best  because  it  may  be 
modified  according  to  circumstances  and  particularly  when  the 
cervix  is  not  in  the  sagittal  plane.  In  such  a  condition  one  can 
avoid  pulling  on  the  cervix  by  making  the  figure  of  8  a  little  more 
oblique ;  but  this  advantage  is  at  the  same  time  an  inconvenience 
because  it  is  more  difficult  to  shape  and  can  only  be  applied  by 
practised  hands. 

11.  Curetting  of  the  Uterus. 

The  curetting  of  the  uterus  has  for  its  object  the  emptying 
of  its  cavity  of  pathological  products,  and  of  removing  in  part 
or  "in  toto"  the  mucous  membrane  which  lines  it. 

History. — It  was  introduced  into  practice  by  Recamier  in 
1846.  Its  practice  was  afterward  abandoned  and  later  restored 
to  a  place  of  honor  in  the  treatment  of  malignant  tumors  by 
Simon  in  1872,  and  in  cases  of  endometritis  by  Hegar,  Kalten- 
bach,  and  Olshausen  in  Germany,  and  by  Doleris  in  France. 
This  renaissance  of  curetting  has  been  followed  for  many  years 
by  a  great  abuse  in  its  employ.  To-day  its  employ  is  justly  more 
restricted,  but  nevertheless  its  indications  are  still  very  numerous. 

Technic. — Providing  there  is  no  call  for  immediate  action  it 
is  as  well  to  choose  one's  time.  We  operate  five  or  six  days 
after  menstruation  and  prepare  the  patient  with  a  bath,  an 
evacuation  of  the  intestine,  and  a  preliminary  dilatation  of  the 
uterus. 


CURETTING  OF  THE  UTERUS  61 

The  last-named  measure  has  the  advantage  of  creating 
a  roomy  canal  which  permits  an  easy  manipulation  of  the 
curette  and  a  way  of  escape  for  intrauterine  secretions ;  it  dimin- 
ishes also  the  irregularity  of  the  cervical  canal,  levels  the  surfaces 
and  renders  the  actions  of  the  instruments  more  efficacious. 

A  curetting,  if  it  is  performed  without  the  preliminary 
dilatation,  is  often  incomplete  and  constitutes  a  poor  operation. 
With  the  exception  of  the  puerperal  condition  we  advise  the 
slow  to  the  rapid  dilatation.  One  can  use  uterine  dilators  or  bou- 
gies to  complete  the  dilatation  commenced  with  laminaria  tents. 

Dilatation  produced  slowly  has  the  advantage  of  making  the 
uterine  tissue  more  flexible  and  of  avoiding  the  tears  which 
follow  on  an  attempt  to  make  the  uterine  canal  of  the  dimen- 
sions \ve  recommend.  In  addition,  note  that  the  cavity  dilated 
by  slo\v  methods  contracts  on  itself  much  less  rapidly  than  one 
dilated  just  at  the  moment  of  the  operation  which  to  our  mind 
constitutes  still  another  advantage. 

Anesthesia. — While  recognizing  that  one  may  practise  curet- 
ting without  anesthesia  it  is  nevertheless  painful  enough  to 
justify  its  use. 

Besides  suppressing  pain,  anesthesia  permits  the  drawing 
down  of  the  cervix  and  a  relaxation  of  the  abdominal  wall, 
which  is  of  use  during  the  operation. 

In  obstetrical  curetting,  particularly  when  the  patient  is 
enfeebled  by  repeated  hemorrhages  or  by  a  severe  infection, 
anesthesia  is  contraindicated.  However,  if  one  has  to  deal 
with  a  pusillanimous  patient,  one  may  be  permitted  to  give  a 
few  inhalations  of  chloride  of  ethyl. 

Operation.— The  patient  is  placed  in  the  dorso-sacral  position 
with  the  buttocks  resting  on  the  extremity  of  the  table,  the  legs 
placed  in  supports  and  the  thighs  flexed  and  abducted. 

We  next  proceed  to  the  cleansing  of  the  region  of  operation. 
It  is  useless  to  shave  the  mons  veneris.  It  is  sufficient  to  shave 
the  labia  majora.  The  vulva  should  afterwrard  be  well  cleansed 
with  soap  as  also  the  vagina.  Finally  these  parts  are  thoroughly 
irrigated. 

The  surgeon  sits  facing  the  vulva,  having  to  his  right  the 
instruments  and  on  his  left  an  assistant  ready  to  take  a  dilator 
or  to  manage  the  cleansing  process. 


62 


MINOR   GYNECOLOGY 


Having  found  the  cervix,  depress  the  posterior  vaginal  wall 
with  the  speculum  and  take  out  the  laminaria  tent.  Then  seize 
the  cervix  with  tenaculum  forceps,  grasping  the  posterior  lip 


FIG.  66. — Patient  in  position  for  curetting. 

generally  about  1    or  2   cm.    (|"— •  \")   from   its   free  border,  in 
order  to  avoid  tearing  it.     We  have  given  up  the  bullet  forceps, 

I 


FIG.  67. — Tenaculum  forceps  for  drawing  down  the  cervix. 


which  tears  the  cervix  so  easily;  also  those  forceps  with  sliding 
ratchets  because  these  form  in  the  interior  of  the  cervical 
cavity  a  troublesome  projection.  Having  seized  the  cervix,  draw 


CURETTING  OF  THE  UTERUS  63 

it  gently  and  gradually  down  to  the  vulva.  A  second  forceps  is 
placed  on  the  anterior  lip  and  the  posterior  speculum  is  taken  out. 

The  drawing  down  of  the  cervix  has  the  advantage  of  straight- 
ening the  uterine  canal,  of  facilitating  the  introduction  of  instru- 
ments and  of  suppressing  the  oscillatory  movements  given  to  the 
organ  during  curettage  manipulations. 

With  the  hysterotome  one  can  find  out  the  direction  and  depth 
of  the  uterine  cavity.  If  the  dilatation  is  insufficient  it  may  be 


FIG.  68. — Uterine  curette. 

completed  with  the  aid  of  Hegar's  dilators ;  then  one  can  proceed 
to  the  curettage. 

There  are  a  great  number  of  models  of  curettes.  Specially 
useful  are  those  of  moderately  sharpened  edge. 

It  is  well  to  have  two  or  three  of  different  calibers.  In  order 
to  enter  into  the  uterine  cornua,  a  little  ring  curette  is  very  useful. 

To  be  quite  efficacious,  curettage  should  be  methodically  done. 
One  should  begin  by  pushing  the  instrument  gently  in  until  it 
comes  into  contact  with  the  fundus.  Then  proceed  to  curette 
both  walls  of  the  cavity  from  above  downward.  First  of  all  the 
soft  tissue  is  removed,  the  debris  of  the  inflamed  mucous  mem- 


- 


FIG.  69. — Ring  curette. 

brane.  One  repeats  the  manipulation  on  the  same  wall  several 
times  until  one  feels  the  special  grating  sensation  described  in 
France  under  the  name  of  "cri  uterin,"  a  sensation  which  is  of 
touch  rather  than  of  hearing.  One  should  support  the  wall 
which  one  curettes  with  the  aid  of  the  index-finger  of  the  left 
hand  introduced  into  the  fornix  corresponding  to  the  anterior 
or  posterior  \vall  of  the  uterus  wrhich  one  is  scraping. 

The  curette  should  be  brought  out  to  the  external  os  with 
each  sweep  of  the  curette  in  order  to  bring  out  of  the  cavity  the 
clots  and  mucous  membrane  debris. 

From  time  to  time  wash  the  curette  with  sterilized  water 


64  MINOR   GYNECOLOGY 

or  an  antiseptic  solution  in  order  to  empty  it  of  the  scraping 
which  fills  its  cavity. 

At  the  level  of  the  cervix  where  the  epithelial  crypts  are  deeper 
and  lesions  more  pronounced  than  elsewhere  the  curettage 
should  be  more  particularly  energetic.  One  should  be  particular 
to  scrape  also  the  angles  of  the  uterine  cavity  with  care,  and  for 
this  purpose  the  ring  pessary  is  best. 

Generally  the  uterus  contracts  during  the  curettage;  excep- 
tionally its  cavity  increases  in  size  and  the  curette  misses  the 
resistance  it  felt  a  moment  before  and  one  is  led  to  think  of 
uterine  perforation.  One  must  then  immediately  withdraw  the 
instrument  and  press  through  the  abdominal  wall  the  uterine 
globe  which  can  easily  be  seen;  as  a  result  a  certain  quantity  of 
blood  comes  out  and  the  organ  contracts  again  and  one  is  enabled 
to  continue  the  curettage. 

We  are  accustomed  to  finish  with  a  curette  attached  by  a 


FIG.  70. — Irrigating  curette. 

tube  to  an  irrigating  can,  which  combination  has  the  advantage 
of  emptying  the  cavity  of  debris  and  at  the  same  time  completes 
the  cleansing  of  the  angles  of  the  uterus. 

After  douching  in  this  manner,  cauterize  the  uterine  cavity 
with  a  mixture  of  creosote  and  glycerine  (creosote  1  part, 
glycerine  2  to  5  parts)  or  with  a  solution  of  chloride  of  zinc 
(1  to  10). 

Doleris  has  introduced  a  special  brush  for  this  stage  of  the 
operation.  We  use  a  simple  vaginal  dressing  forceps  armed 
with  some  hydrophile  wool.  Having  impregnated  the  wool 
with  some  caustic  fluid,  we  successively  rub  the  wralls  of  the 
uterus,  executing  movements  from  below  upward  and  of  rotation. 
The  portion  of  wool  we  use  should  extend  far  enough  down  the 
forceps  in  order  not  to  entirely  enter  the  uterine  cavity,  the 


CURETTING  OF  THE  UTERUS  65 

neglect  of  this  precaution  often  leading  to  the  catching  of  the 
wool  just  above  the  cervix  when  the  forceps  are  withdrawn. 

During  the  cauterization  be  careful  to  place  on  the  posterior 
fornix  a  tampon  of  wool  in  order  to  catch  the  excess  of  the  caustic 
fluid  which  may  discharge  and  burn  the  vagina. 

Finally,  drain  the  uterine  cavity.  A  gauze  drain  is  generally 
used,  but  we  prefer  a  rubber  drain.  Once  the  gauze  is  well 
saturated  with  the  products  of  the  secretions,  there  is  a  risk  of 
complications  resulting  from  retention  provided  the  gauze  has 
not  been  accurately  placed  in  contact  with  the  uterine  walls. 
A  stick  of  iodoform  has  also  been  recommended  for  introduction 
into  the  uterus. 

As  a  last  precaution  we  tampon  the  vagina  lightly  with 
iodoform  gauze. 

After-treatment. — Excepting  the  occurrence  of  complications 


FIG.  71. — Doleris'  brush. 

such  as  arise  of  temperature  we  remove  the  dressings  on  the 
third  day.  If  there  is  well  marked  oozing  through  the  vaginal 
tampon,  we  change  it  earlier.  We  take  out  the  tampon,  irrigate 
the  vagina  freely,  and  insert  a  smaller  drain  into  the  uterine 
cavity  and  again  lightly  pack  the  vagina  with  iodoform  gauze. 
The  second  dressing  is  usually  done  on  the  sixth  day  and  after 
that  the  uterine  drainage  is  dispensed  w^ith.  About  the  ninth 
day  we  relinquish  the  vaginal  tamponing  and  give  once  daily  a 
free  vaginal  irrigation.  The  patient  should  have  the  bow^els 
opened  on  the  third  day. 

The  confinement  to  bed  should  generally  be  about  ten  days; 
perhaps  it  may  be  necessary  to  prolong  this  interval  to  three 
weeks  where  there  is  an  imperfect  involution  of  the  uterus,  and 
for  special  reasons.  It  is  of  advantage  to  restrain  from  sexual 
communication  for  about  six  weeks. 

Complications. — Curettage  may  be  the  cause  of  certain 
complications,  those  produced  during  the  operation  and  those 
resulting  more  or  less  from  it. 


66  MINOR   GYNECOLOGY 

Perforation. — The  operator  may  perforate  the  uterus.  This 
accident  is  most  apt  to  occur  when  the  curettage  is  done  at  a 
time  approaching  confinement. 

There  is  generally  little  danger  if  the  operator  stops  at  once 
and  places  a  drain  or  an  iodoform  gauze  drain  immediately  in 
the  uterine  cavity. 

Cases  have  occurred  of  operators  making  veritable  ruptures 
in  the  uterine  wall.  In  a  case  reported  by  Hoffmann,  the 
epiplocele  engaged  in  the  wound  in  the  uterus  and  penetrated 
as  far  as  the  orifice  of  the  cervix.  Hessert1  was  obliged  to  open 
the  abdomen  and  resect  a  segment  of  the  intestine,  which  the 
curette  had  injured.  Many  a  time  the  suppuration  of  the  pelvic 
cavity  has  been  recorded. 

Hemorrhage. — It  is  rare  to  find  that  the  bleeding  accom- 
panying curetting  assumes  proportions  wrhich  cause  inquietude. 
If  a  serious  hemorrhage  is  produced  during  the  operation,  it 
generally  results  from  a  too  superficial  curetting  and  it  can 
best  be  dealt  with  by  completing  and  terminating  the  scraping 
of  the  diseased  and  bleeding  mucosa.  If,  however,  the  hemor- 
rhage persists,  it  might  be  necessary  to  do  an  intrauterine 
tamponing. 

Secondary  hemorrhages  coming  on  some  days  after  the 
operation  are  exceptional  and  result  from  infection  of  the 
uterine  cavity. 

Infection. — Complications  of  infection  result  from  a  faulty 
technic.  It  behooves  the  surgeon  to  avoid  them. 

If  one  observes  after  curetting  a  slight  rise  of  temperature, 
this  may  be  due  to  a  defective  drainage.  It  is  possible  that 
the  gauze  plug  is  acting  as  a  tampon  and  preventing  the  uterine 
secretions  escaping.  It  is  therefore  indicated  to  remove  the 
plug  and  replace  with  a  drain.  A  fall  in  temperature  to  37°  C. 
or  98°  Fahr.  is  the  result. 

Graver  complications  of  infection  may  come  on  as  a  result  of 
the  operative  or  postoperative  septic  involvement  of  the  raw 
surface  created  by  the  scraping  away  of  the  mucous  membrane. 
This  septic  endometritis  is  combated  with  free  intrauterine 
douches  repeated  several  times  a  day.  If  these  septic  compli- 

1  Hessert  (William),  Accidental  Perforation  of  the  Uterus  during  Curetting.  A  case 
with  bowel  injury  and  resection  of  four  feet  of  the  small  intestine.  (Am.  Journal  of 
Obstetr.,  Phila.,  1905,  T.  L,  p.  26). 


CURETTING  OF  THE  UTERUS  07 

cations  persist,  we  may  have  to  perform  hysterectomy  in  order 
to  avoid  a  generalized  infection  occurring. 

In  other  cases,  finally,  the  temperature  rise  results  from  an 
involvement  of  the  adnexa.  This  condition  should  be  treated 
with  absolute  repose,  administration  of  opium  and  ice  to  the 
abdomen. 

Sterility,  Stricture  and  Obliteration  of  the  Uterine  Cavity.— 
Sterility  has  been  known  to  come  on  after  curetting.  This 
results  most  often  from  atresia  or  even  a  partial  or  complete 
obliteration  of  the  uterine  cavity.  The  way  this  condition  is 
brought  about  can  be  easily  understood.  It  is  known  how  the 
mucous  membrane  rapidly  regenerates,  after  curetting,  by  the 
multiplication  of  the  cellular  elements  which  line  the  recesses 
of  the  crypts  of  the  mucous  membrane  and  are  ordinarily  spared 
by  the  curette.  If  the  curetting  has  been  too  violent,  these 
cellular  regenerative  nests  may  be  destroyed.  In  such  a  case, 
a  fibrous  cicatrix  is  produced  or  even  a  complete  fusion  of  the 
walls,  leading  to  stenosis  or  obliteration.  This  may  even  extend 
to  the  uterine  cavity  "in  toto."  These  strictures  or  obliterations 
lead  naturally  to  dysmenorrhea  and  sterility. 

We  combat  this  condition  by  slow  progressive  dilatation.  If 
the  stricture  is  situated  interiorly,  near  the  external  os,  a  plastic 
operation  is  indicated.1  In  case  of  extensive  strictures  or  com- 
plete obliteration,  with  the  existence  of  very  painful  complicating 
dysmenorrhea,  hysterectomy  is  the  only  chance.  There  are 
complications  which  we  have  never  observed  and  which  could 
only  arise  by  a  brutal  curetting  and  consequent  injury  of  the 
actual  uterine  muscle. 

Generally  the  mucous  membrane  regenerates  rapidly  and 
reforms  its  accustomed  structure.  The  primary  menstruation 
is  simply  retarded  about  a  month  and  pregnancy  may  come 
on  and  continue  normally. 

Failures. — The  failures  of  curetting  result  most  often  from 
a  faulty  technic,  faulty  asepsis,  an  ill  considered  indication,  an 
existing  cervicitis,  a  suppurating  metritis,  an  inflammation  of 
the  adnexa,  a  postoperative  reinfection,  insufficient  dressing,  or 
a  too  rapid  recommencement  of  sexual  communication. 

If  the  employment  of  curetting  is  strictly  limited  to  cases 

1  See  further  on  the  "  Operations  on  the  Cervix." 


68  MINOR   GYNECOLOGY 

where  it  is  really  indicated,  and  we  will  see  later  its  indications ; 
failures  will  be  seen  only  in  quite  exceptional  cases. 
Indications. — Curettage  may  be  indicated  in : 

(1)  The  puerperal  state. 

(2)  Outside  the  puerperal  state. 

(1)  In  the  Puerperal  State. — The  primary  indication  of  curet- 
ting in  this  state  is  evacuation  of  retained  products,  portions  of 
membrane,  placenta,  etc.,  resting  in  the  uterine  cavity.  If  there 
is  a  free  hemorrhage,  this  evacuation  should  be  done  immediately 
after  the  passage  of  the  fetus;  in  the  absence  of  complications, 
one  should  wait  twenty-four  to  thirty-six  hours  to  see  if  the 
evacuation  will  not  occur  spontaneously. 

Generally  speaking,  the  finger  is  preferable  to  instruments. 
A  curette  may  scrape  the  placenta  without  loosening  it  and  may 
leave  it  "in  toto"  in  the  uterus.  The  finger,  however,  feels  what 
it  is  doing,  feels  what  it  has  to  detach,  and  finds  the  line  of  cleav- 


FIG.  72. — Blunt  curette  for  puerperal  curetting. 

age.  There  is  no  question  that  when  large  placental  masses 
remain  in  the  uterus,  one  should  have  recourse  to  digital  curetting. 

To  do  this  the  cervix  must  not  be  closed  and  one  should  be 
able  to  palpate  through  the  abdominal  wall  to  get  the  necessary 
contra-pressure  so  as  to  carry  out  a  good  intrauterine  palpation. 

In  general,  one  uses  a  combination  of  finger  and  curette, 
using  large  and  blunt  instruments  and  manipulating  them  with 
great  lightness  of  touch. 

When  the  digital  palpation  shows  all  the  placenta  is  removed, 
is  it  necessary  to  curette  the  rest  of  the  cavity  ?  This  question  is 
discussed.  Some  say  that  the  curette  destroys  the  mucous 
membrane  and  even  the  muscle,  that  it  opens  up  vessels  already 
thrombosed  and  prepares  a  wray  for  infection,  and  that  it  sup- 
presses a  degeneration  useful  for  the  regeneration  of  the  mucous 
membrane. 

It  appears  on  the  contrary  that  decidual  retention  favors 
hemorrhage,  the  secondary  development  of  metritis  and  of 


CURETTING  OF  THE  UTERUS  09 

polyps,  and  that  curetting,  after  the  evacuation  of  the  large 
debris  with  finger,  presents  nothing  but  advantages. 

If  one  is  face  to  face  with  an  abortion  of  six  to  eight  weeks, 
one  has  recourse  solely  to  the  curette. 

The  second  indication  of  curetting  during  the  puerperal  state 
is  the  development  of  complications  of  sepsis.  We  have  quoted 
the  objections  to  the  curette.  The  danger  of  perforating  a 
softened  uterine  wall,  of  detaching  a  thrombus,  or  of  bringing 
on  a  profuse  hemorrhage,  the  impossibility  of  removing  all  the 
septic  tissues,  the  risk  of  generalizing  the  infection  by  causing 
the  organisms  to  penetrate  the  open  vessels  and  by  destroying 
the  line  of  defence  against  the  bacterial  infection. 

There  is  some  truth  in  all  these  objections.  Certainly,  in 
severe  infections,  the  uterine  wall  is  often  softened,  particularly 
at  the  level  of  the  placental  insertion ;  but,  by  using  a  broad  blunt 
curette  and  by  palpating  through  the  abdominal  wall  the 
external  surface  of  the  uterus  and  at  the  same  time  manipulating 
the  instrument  in  its  interior,  we  are  enabled  to  avoid  these 
perforations.  Hemorrhage  has  never  appeared  to  us  in  alarming 
quantities  and  has  always  ceased  on  giving  an  intrauterine 
douche  of  hot  water.  The  only  objection  remaining  is  that  of 
a  general  septic  infection.  It  is  certain  that  a  rise  of  temperature 
frequently  occurs  on  the  evening  of  the  day  when  intervention 
was  carried  out  in  a  septic  uterus,  but  this  falls  in  a  few  hours 
and  the  patient  feels  better.  The  curette,  by  emptying  the 
uterus  of  a  large  quantity  of  microbes  and  decaying  tissues 
impregnated  with  septic  organisms,  gets  rid  of  these  organisms 
and  more  or  less  removes  the  "milieu"  of  culture  where  they 
best  develop. 

We  are  advocates  of  curetting,  while  recognizing  that  the 
indications  have  been  exaggerated.  It  is  certain  to  have  been 
abused  in  the  past,  especially  when  used  after  the  first  elevation 
of  temperature  following  an  accouchement.  For  this  condition 
it  is  quite  sufficient  to  perform  a  full  antiseptic  intrauterine 
irrigation  to  see  the  fever  disappear.  If  it  persists,  and  above 
all,  if  it  is  suspected  that  portions  of  membrane,  placenta,  etc., 
remain,  or  there  are  septic  lochia,  empty  the  uterus  completely, 
curetting  it. 

After  the  eighth  day,  curetting,  according  to  some  accoucheurs 


70  MINOR   GYNECOLOGY 

and  particularly  Pinard,1  is  more  harmful  than  useful,  but  at 
that  period  the  infection  has  gone  beyond  the  limits  of  the 
uterus  and  intrauterine  interventions  can  only  bring  about  an 
extension  of  septic  organisms  and  the  provoking  of  salpingitis, 
phlebitis,  etc. 

This  opinion  seems  to  us  exaggerated.  If  salpingitis  and 
phlebitis  appear  to  come  on  after  a  curetting  on  the  seventh  day 
or  twelfth  day,  these  conditions  may  have  caused  the  original 
rise  in  temperature  and  incorrectly  diagnosed  at  the  time  of 
curetting  and  only  apparent  some  days  later.  It  cannot  be 
argued  that  because  these  conditions  come  on  secondarily  that 
they  necessarily  follow  as  a  consequence  of  intervention. 

It  is  most  important,  before  concluding  the  curetting,  to  find 
out  the  cause  of  the  fever.  It  seems  certain  that  after  the  first 
week,  this  fever  seems  to  be  connected  with  an  extrauterine 
trouble  and  we  must  investigate  this.  But  if  nothing  exists  to 
cast  suspicion  on  an  extrauterine  condition  and  if  on  the  con- 
trary the  presence  of  a  uterine  discharge  leads  one  to  think  of 
the  putrefaction  of  some  retained  product,  there  should  be  no 
hesitation.  A  rise  of  temperature  during  the  first  day  or  two 
following  should  lead  us  to  think  of  an  intrauterine  trouble  and 
curetting  has  its  value  then.  It  is  necessary  to  irrigate  with 
antiseptic  solution  later,  once  the  uterus  has  been  emptied,  and 
place  in  a  drain  to  secure  discharge  of  the  uterine  secretions. 

It  is  very  evident  that  when  profound  toxemia  exists  and  a 
cellulitis,  phlebitis  or  a  peritonitis  manifests  itself,  the  question 
of  the  indication  of  curetting  does  not  come  forward. 

On  the  contrary,  when  after  an  operation  there  has  been  a 
temporary  amelioration  of  symptoms  and  complications  reap- 
pear, the  indication  is  for  another  curetting. 

(2)  Apart  from  the  Puerperal  State. — Apart  from  the  puerperal 
state,  curetting  can  be  carried  out  as  a  means  of  exploration,  as  a 
curative  treatment,  and  as  a  palliative  treatment. 

A.  Exploratory  Curetting. — In  certain  cases  of  uterine  hem- 
orrhage of  an  insufficiently  determined  origin,  and  particularly 
if  an  intrauterine  epithelioma  is  suspected,  one  should,  without 
delay,  curette.  If  it  is  a  question  of  simple  inflammation,  that 

1  See  the  discussion  of  the  Socie'te'  d'obste'trique,  de  gyne'cologie  et  de  pe'diatrie  of 
April  and  May,  1905,  and  also  Pasturaud,  La  curettage  £  la  clinique  Baudelocque.  Tin,, 
de  Paris,  1905-1906,  No.  38. 


CURETTING  OF  THE  UTERUS  71 

will  be  the  best  means  of  curing  it;  if  it  is  a  question  of  epithelioma, 
the  diagnosis  may  be  made  early  enough  to  hope  for  a  cure  with 
a  radical  operation. 

Curetting  should  always  be  done  completely.  In  the  first 
place,  because  it  will  only  lead  to  a  cure,  if  all  the  diseased  parts 
of  the  mucous  membrane  are  removed;  in  the  second,  because 
a  cancer  at  the  beginning  may  be  localized  to  only  a  small  part  of 
the  cavity,  and  if  the  curetting  is  not  complete,  it  may  pass  unper- 
ceived.  In  short,  we  reject  completely  and  absolutely  all  curette 
explorations  which  are  done  without  preliminary  dilatation  and 
remove  a  small  piece  of  tissue  for  examination. 

B.  Curetting  as  a  Curative  Agent. — The  triumph  of  curetting 
as  a  means  of  cure  is  chronic  hemorrhagic  endometritis.     Curet- 
ting  can   also  render  service  in  hemorrhagic  glandular  hyper- 
trophies observed  even  in  virgins  and  certain  cases  of  sterility; 
combined  with  dilatation,  it  is    often   enough  observed   to  be 
followed  by  conception.     American  gynecologists  freely  accept 
this  as  an  indication  for  curetting.     The  existence  of  inflamma- 
tory conditions  of  the  adnexa  contraindicate  curetting;  a  slight 
intervention  in  the  uterine  cavity  even  may  lead  to  the  lighting 
up  of  these  troubles  and  be  the  origin  for  the  provoking  of  a  pelvic 
peritonitis. 

C.  Curetting    as    a   Palliative    Agent. — Curetting    has  been 
practised  often  enough  under  the  heading  of  palliative  treatment 
in  order  to  combat  hemorrhages  connected  with  little  fibromata. 
We  do  not  feel  inclined  to  advise  it  in  these  cases — seeing  that 
only  a  temporary  relief  is  obtained  in  these  cases  and  the  patient 
is  exposed  sometimes  to  inflammatory  complications  following 
the  treatment,  such  as  the  deformation  of  uterine  cavity,  badly 
drained,  and  often  infected,  which  may  perhaps  lead  to  these 
complications. 

On  the  contrary,  in  cancer,  may  be  of  the  cervix  or  of  the 
body,  curetting  is  most  useful  when  abundant  hemorrhages  exist, 
and  also  fetid  discharges.  By  suppressing  for  a  time  the  cancer- 
ous outgrowths,  the  patients  are  greatly  relieved. 

The  first  sweep  of  the  curette  sometimes  brings  on  an  abun- 
dant hemorrhage  and  as  no  means  exist  to  stop  it  we  must  rapidly 
continue  the  operation.  If  all  the  friable  cancerous  masses  are 
removed,  hemorrhage  stops  of  itself.  If  some  debris  from  the  cer- 


72  MINOR  GYNECOLOGY 

vix  still  remain  fixed  and  float  about  in  the  cavity,  excise  them 
with  the  scissors,  attach  artery  forceps  and  tie,  if  one  can,  the 
bleeding  vessels.  When  the  curetting  is  finished  and  the  cavity 
well  cleansed,  pass  the  thermo-cautery  over  its  walls  and  tampon 
with  iodoform  gauze  which  may  be  removed  in  three  or  four  days. 
It  is  sometimes  astonishing  to  see  the  way  in  which  the  parts 
recover,  and  where  at  the  vaginal  fundus  one  had  left  a  cavity, 
quite  irregular  in  outline,  a  sort  of  cervix  re-forms  which  would 
give  no  suspicion  of  the  previous  existing  conditions.  The  patients 
are  greatly  relieved,  become  more  healthy  looking,  and  increase 
in  weight  and  for  the  time  believe  themselves  cured. 

Unfortunately,  at  the  end  of  a  variable  period,  the  old  troubles 
once  more  appear,  either  the  hemorrhagic  losses  or  others.  Again 
one  may  recommence  curetting  and  if  not  to  prolong  life,  make 
it  more  pleasurable. 

In  the  course  of  these  curettings  one  may  open  the  recto- 
uterine  sac  (pouch  of  Douglas)  as  a  result  of  cancerous  extension. 
This  accident  is  not  so  grave  as  one  \vould  think  a  priori.  It 
suffices  to  insert  an  iodoform  gauze  drain  at  the  level  of  the  per- 
foration to  see  the  healing  rapidly  proceed. 

The  opening  of  the  bladder  itself,  much  rarer  than  the  other, 
closes  as  a  rule  spontaneously  in  a  brief  period.  Nevertheless, 
we  advise  to  abstain  from  intervention  wrhen  we  find  by  examina- 
tion a  propagation  of  the  disease  to  that  organ.  This  is  even 
more  to  be  observed  when  the  rectum  is  involved. 

In  closing,  we  should  like  to  add  that  the  curetting  of  cancer 
is  still  indicated  as  the  first  act  in  the  big  operation  of  excision, 
and  this  we  will  deal  with  later  in  the  various  procedures  of 
hysterectomy. 


CHAPTER  III. 

PHYSICAL  AGENTS  IN  GYNECOLOGY. 

Summary. — Electrotherapy   (instruments,   physiological   bases,   indica- 
tions).— Kinesitherapy. — Hydrotherapy. — Mineral  waters. 

1.  Electrotherapy.1 

Electricity  has  many  and  varied  uses  in  gynecology.  It 
would  be  wrong  to  imagine  that  electrotherapy  is  of  as  great  a 
magnitude  as  the  medical  and  surgical  therapy.  Electricity  has 
its  place  ainong  other  agents  in  the  treatment  of  the  diseases  of 
women,  and  its  indications  are  supported  by  experiments  now 
quite  old,  and  by  the  more  recent  developments  of  electrophy- 
siology.  This  latter  science's  development  has  considerably 
diminished  the  empiricism  in  electrotherapy,  and  among  the 
gynecological  indications  there  are  hardly  any  which  cannot  be 
supported  by  rational  and  precise  experiment  and  observation. 

The  majority  of  affections  demand,  in  their  electrical  treat- 
ment, few  instruments  of  a  simple  nature,  which  could  be  the 
property  of  every  practitioner.  Those  are  rarer  which  require 
an  outfit  of  instruments  of  a  more  complicated  nature,  and  which 
consequently  constitute  more  the  arsenal  of  the  specialist. 

Instruments.  Physiological  Bases. — With  a  good  pile  battery 
and  a  constant  current,  the  gynecologist  is  in  a  position  to  do  a 
great  deal.  If  he  possesses  in  addition  a  means  of  procuring 
high  frequency  currents,  and  an  X-ray  apparatus,  he  will  be  able 
to  do  everything.  These  latter  lie,  however,  more  in  the  province 
of  professional  electricians  and  are  besides  very  difficult  to 
transport. 

A  good  battery  for  the  production  of  a  continuous  current 
should  comprise  about  thirty  elements.  The  most  practical  type 
is  the  bisulphate  of  mercury  pile,  the  price  of  which  is  moderate 
and  its  longevity  remarkable.  These  instruments  are  always 

1  All  the  electrotherapy  text  has  been  drawn  up  by  M.  Zimmern,  professoi  of  physics, 
Paris  University. 

73 


74 


PHYSICAL   AGENTS   IN   GYNECOLOGY 


furnished  with  a  graduated  scale,  which  enables  us  to  use  the 
current  at  a  desired  strength,  also  with  a  measuring  instrument, 
milliarnpere-meter,  the  electrotherapeutist's  scale,  as  it  has  been 
called,  which  enables  us  to  find  out  at  any  moment  the  intensity 
of  the  electrical  application  we  are  making. 

Two  electrodes,  one  fixed  to  the  copper  pole  (+)  of  the  bat- 


FIG.  73. — Portable  battery  of  bisulphate  of  mercury  (L6zy's  model). 

tery,  the  other  to  the  zinc  (— )  form  the  contact  of  the  current. 
Two  wires  place  these  in  communication  with  the  instruments 
which  carry  the  current  to  the  tissues.  These  instruments  are 
called  electrodes. 

The  electrodes  are  either  metallic  or  spongy.     The  latter  con- 
sist of  a  metallic  plate  covered  over  with  several  layers  of  hydro- 


FIG.  74. — Spongy  electrodes. 

phile  gauze  or  even  better  of  plaited  hydrophile  cotton.  These 
are  plunged  into  lukewarm  water  which  is  to  a  certain  extent  re- 
tained in  the  meshes  of  the  tissue.  They  are  generally  applied 
to  the  abdominal  wall.  As  these  electrodes  have  no  special  action 
at  the  seat  of  contact,  but  are  only  of  use  to  create  the  electric 


ELECTROTHERAPY 


75 


circuit  on  the  abdomen,  they  are  called  indifferent  electrodes,  in 
contradistinction  to  those  others  which  are  introduced  and  applied 
to  a  point  in  the  genital  canal  and  are  called  active  electrodes. 

Active   electrodes   are   made   of   metal    or   of  horn  carbon. 
They  are  shaped  like  sounds  and  are  made  of  platinum,  copper, 


Their  stem 


FIG.  75. — Active  electrode. 

zinc,  nickel,  or  silver.  They  are  fixed  on  a  conducting  handle, 
which  the  doctor  holds,  and  surrounded  by  an  isolating  sheath 
which  in  intrauterine  manipulations  protects  the  vaginal  walls 
from  the  effects  of  the  current. 

The  carbon  sounds  are  shaped  like  a  little  reed, 
is  isolated.  Of  the  two  extremities  one,  M,  is 
attached  to  the  conducting  wire,  the  other,  C,  car- 
ries the  current  into  the  uterine  cavity. 

At  other  times  the  carbon  sounds  are  utilized 
not  as  intrauterine  electrodes,  but  as  vaginal  ones. 
In  such  cases  they  are  enveloped  in  a  triple  layer 
of  hydrophile  cotton,  and  later  are  soaked  in  water, 
in  order  to  transform  them  into  spongy  electrodes 
and  in  order  not  to  injure  the  walls  of  the  vagina 
by  cauterizing  them.  They  are  introduced  into  the 
posterior  vaginal  fornix. 

The  electrode  covered  with  moistened  hydro- 
phile cotton  is  exclusively  reserved  to  vaginal  ap- 
plications. The  plane  electrodes  on  the  contrary 
are  used  for  intracervical  or  intrauterine  applica- 
tions. 

It  is  generally  easy  enough  to  introduce  a  hys- 
terometer,  at  least  into  the  cervical  canal,  without 
inspection.  The  speculum  is  usually  more  trou- 
blesome than  useful.  With  the  second  and  index- 
fingers  of  the  left  hand,  a  little  gutter  is  formed 
along  which  the  instrument  is  made  to  glide  into 
the  cervical  canal.  In  certain  cases  the  conforma- 
tion or  flexion  of  the  uterus  prevents  its  penetration 


FIG.  76.— Carbon 
electrode. 


76 


PHYSICAL   AGENTS   IN   GYNECOLOGY 


farther,  but  it  is  at  times  possible,  either  by  depressing  the  fun- 
dus  of  the  anteflexed  uterus  with  the  right  hand  placed  on  the 
abdomen,  or  by  inclining  the  cervix  posteriorly  with  the  hys- 
terometer  itself,  to  introduce  the  instrument  right  up  to  the 
fund  us. 

These  manipulations,  be  it  understood,  are  made  with  patience 
and  gentleness  and  it  is  useless  to  add  with  a  perfect  aseptic 
technic  of  hands  and  instruments. 

The  physiological  properties  of  the  continuous  current  are 
chemical  and  motor. 

(a)    The  chemical  actions  may  be  understood  from  a  study  of 


FIG.  77. — Vaginal  application.     The  electrode  is  in  the  posterior  fornix. 

electrolysis.  It  is  known,  however,  from  the  study  of  these 
phenomena  that  we  may  compare  the  organism  to  an  electrolyte 
consisting  of  chloride  of  sodium;  in  other  words,  to  a  substance 
decomposed  by  the  continuous  current.  Physical  chemistry 
teaches  us  that  a  solution  of  sodium  chloride  contains  fragments 
of  molecules  called  ions  and  literally  charged  with  electricity. 
Some  are  positive,  some  negative  and  if  the  number  of  +  is  equal 
to  the  number  of  —  ions,  they  neutralize  each  other,  and  the  solu- 
tion is  electrically  neutral.  Now,  if  by  passing  a  current  through 


ELECTROTHERAPY  77 

such  a  solution  one  can  create  a  difference  of  the  potential,  the  + 
ions  or  anions  go  to  the  negative  pole  and  the  —  ions  or  cations  to 
the  positive  pole.  On  contact  of  the  two  poles  the  electric  dis- 
charges destroy  each  other  and  the  molecular  fragment  deprived 
of  its  electrical  charge  becomes  a  free  atom.  At  the  positive  pole 
in  our  above  considered  electrolyte,  the  atom  Cl.  will  be  deposited 
and  at  the  negative  pole  the  atom  Na.  By  a  secondary  reaction 
these  atoms  'will  enter  into  combination  with  the  water  of  the 
electrolyte  with  the  result  that  at  the  positive  pole  we  get  a  forma- 


FIG.  78. — Intrauterine  application.     The  right  hand  presses  down  the  fundus  of  the 

anteflexed  uterus. 

tion  of  hydrochloric  acid  with  a  liberation  of  oxygen  and  at  the 
negative  pole,  soda  with  liberation  of  hydrogen.  These  elements, 
in  proportion  to  their  production,  exercise  what  is  known .  as 
a  tertiary  action  on  the  tissues,  which  varies  either  according  to 
the  pole  (acid  cauterization  at  +  pole  and  basic  cauterization  at 
the  pole)  or  according  to  the  concentration  of  the  acid  or  the 
base  formed.  A  feeble  concentration  and  a  feeble  current 
produce  only  modifying  effects;  a  powerful  concentration  and 
powerful  current  produce  caustic  effects. 

The  positive  pole  is  above  all  employed  as  an  acid  caustic  in 
order  to  modify  the  uterine  mucous  membrane,  but  its  essential 
utility  springs  from  its  coagulating  properties  attributed  to  the 


78  PHYSICAL   AGENTS   IN    GYNECOLOGY 

acids  formed.  This  is,  at  least,  a  theory  which  has  long  held 
pride  of  place,  but  which  is  opposed  by  the  feeble  coagulating 
power  of  hydrochloric  acid. 

It  would  appear  that  the  negative  pole  produces  clinically 
analogous  hemostatic  effects  and  of  such  a  kind  that  it  has  been 
thought  necessary  to  furnish  another  explanation  of  the  arrest  of 
uterine  hemorrhages  by  the  continuous  current. 

The  importance  of  the  negative  pole  springs  from  the  fact 
that,  placed  in  contact  with  sclerosed  or  cicatricial  tissues,  it 
changes  their  consistence  by  a  process  still  unknown,  but  unde- 
niable and  which  is  currently  known  under  the  name  of  sclerotic 
action.  We  can  prove  this  action  in  the  following  manner:  Cut 
a  hard-boiled  egg  in  half;  stand  it  on  its  base  in  a  glass  sur- 
rounded by  a  thin  layer  of  wrater.  Make  contact  between  the 
water  and  one  of  the  poles  of  the  pile  writh  a  metallic  electrode, 
and  connect  up  the  pointed  end  of  the  egg  wTith  a  metallic 
rod,  which  is  held  vertically  and  in  communication  with  the 
other  pole  of  the  pile.  If  this  rod  is  attached  to  the  positive  pole 
and  a  current  of  5  to  10  milliamperes  turned  on,  no  change 
occurs.  Now,  however,  if  the  rod  is  attached  to  the  negative 
pole,  it  is  observed  to  sink  into  the  albumen  and  by  its  own 
weight  transfixes  the  egg.  This  is  an  elementary  experiment 
which  shows  the  specific  flexibility  producing  action  of  the 
cathode.  Based  on  this  action  is  the  treatment  by  the  elec- 
trolysis of  strictures  of  canals  such  as  the  urethra  and  esoph- 
agus, etc. 

The  action  of  acids  developed  at  the  positive  pole  is  made  use 
of  in  actions  on  the  tissues  wrhen  platinum,  nickel  or  carbon  hys- 
terometers  are  used.  But  if  metals  like  copper,  zinc  or  silver 
are  used,  there  is  a  simultaneous  attack  of  the  metal  by  the 
hydrochloric  acid  and  the  formation  of  a  metallic  salt  which  is 
in  all  probability  an  oxychloride  of  the  metal  used.  This  new 
body  then  behaves  as  an  electrolyte,  that  is  to  say,  the  ions  are 
displaced,  and  the  positive  ions  are  drawn  toward  the  cathode. 
The  result  of  this  is  that  the  metal — a  positive  ion — penetrates 
more  or  less  deeply  into  the  tissues.  This  action,  formerly 
described  under  the  name  of  cataphoresis  or  interstitial  electrolysis, 
is  known  to-day  as  electrolytic  introduction  of  metallic  ions.  . 

The  silver  ion  is  one  of  those  which  is  said  to  be  most  effica- 


ELECTROTHERAPY  79 

cious.  Its  employment  in  electrotherapy  by  the  gynecologist  has 
preceded  by  a  lengthy  period  the  therapeutic  agents  colloidal, 
protargol  and  collargol,  etc. 

The  zinc  ion  was  introduced  by  Leduc,  as  possessing  most 
precious  coagulating  properties  and  is  consequently  used  in 
uterine  hemorrhages. 

(b)  Motor  Actions. — It  is  known  that  the  sudden  closing  or 
breaking  of  a  continued  current  produces  a  contraction  of  striated 
muscle.  This  contraction  is  sudden  and  rapid  as  lightning.  If 
a  continuous  current  passing  through  a  muscle  is  suddenly 
broken,  the  striated  muscle  contracts  at  the  precise  moment  of 
the  break  while  the  passage  of  the  continuous  current  has  no 
action  upon  it. 

It  is  not  the  same  with  non-striated  muscle.  A  break  or  a 
rapid  closing  of  the  continued  current  is  without  any  influence 
on  the  elements  unprovided  with  fibrillar  substance.  The 
sarcoplasm  only  permits  of  being  excited  by  a  stimulus  extending 
over  a  longer  duration,  that  is  to  say,  by  an  extended  wave.  Those 
who  practice  electro-diagnosis  know  that  while  striated  muscle 
normally  replies  to  the  short  closings  and  openings  of  a  current, 
when  degenerated  it  demands  a  prolonged  stimulus.  The  mus- 
cular contraction  is  in  these  cases  a  slow  and  worm-like  move- 
ment. Thus  we  see  that  degenerated  striped  muscle  behaves 
as  smooth  muscle  does  normally. 

It  is  the  extended  wave  of  the  continuous  current  wrhich  is 
suited  to  the  intestines  and  which  is  employed  in  the  so-called 
electric  douche ;  this  same  is  also  best  suited  to  the  stimulus  of  the 
smooth  uterine  muscle,  when  its  contractile  powers  are  about  to 
be  stimulated. 

Let  us  add  that  the  excitability  of  smooth  muscle  fiber  pro- 
ceeds more  or  less  for  some  time  after  the  application  and  it  is 
exhibited  in  the  intestine  by  increased  peristalsis  and  in  the  uterus 
by  an  awakening  of  its  muscular  function. 

Such  are  the  essential  physiological  principles  on  which  are 
based  the  application  of  the  continuous  current  in  gynecology. 

High  frequency  currents  result  from  the  discharge  of  con- 
densers. Generally  their  tension  is  raised  by  an  apparatus  called  a 
resonator,  at  the  extremity  of  which  a  current  or  spark  is  received. 
Appropriate  electrodes  complete  the  installation.  These  high 


80  PHYSICAL   AGENTS   IN    GYNECOLOGY 

frequency  currents  create  modifications  in  the  local  circulation. 
For  this  purpose,  they  are  used  as  anti-congestion  agents  and  to 
hasten  the  repair  of  wounds.  Note,  also,  that  a  remarkable 
analgesic  power  accompanies  these  actions. 

The  spark  has  been  recommended  as  a  cancer  cure,  and  the 
great  advertisement  it  received  enables  us  to  omit  its  description. 
However,  we  have  learned  that  the  electric  spark  does  not  destroy 
the  neoplasmic  cell  and  that  all  the  good  results  said  to  come 
from  fulguration  may  be  attributed  partly  to  the  simple  removal, 
partly  to  the  cicatrizing  or  ulitic1  action,  as  we  have  called  it, 
of  the  high  frequency  current. 

The  X-rays  have  also  their  use  in  gynecology.  It  is  known 
how  these  invisible  rays  are  produced  from  electrical  energy  by  its 
passage  through  a  rarefied  gas.  Their  injurious  action  on  the  in- 
tegument and  the  radio-dermatitis  produced  has  formed  the  basis 
of  numerous  therapeutic  experiments.  As  the  result  of  much 
patient  work  contributed  by  all  the  leading  radiologists  of  the 
world,  we  learn  that  X-rays  possess  a  specific  action,  which  is 
elective  on  the  cellular  elements  of  the  blood,  the  spleen,  the 
genital  organs  and  skin.  A  sufficient  charge  of  X-rays  will 
destroy  the  white  corpuscles,  the  white  cells  of  the  spleen  and 
medullary  cavities  and  the  cellular  elements  of  the  testicle,  sper- 
matogonia  and  spermatocytes,  the  ovules,  and  epithelial  tissues. 
These  strictures  are  broken  down  and  reabsorbed. 

The  sensibility  of  epithelial  tissue  in  direct  contact  with 
X-rays  has  led  to  their  employ  in  treatment  of  neoplasms  where 
much  success  has  been  obtained.  Unfortunately  the  very  rapid 
absorption  of  the  rays  by  the  superficial  strata  limits  their  action 
at  any  depth,  and  it  would  seem  to  be  of  little  use  for  deeply  seated 
neoplastic  growths. 

It  has  been  suggested  that  X-rays  may  be  used  for  rendering 
women  sterile,  but  it  has  been  held  by  others  that  such  a  liberty 
of  practice  would  be  a  great  social  evil.  There  is  no  doubt  that 
the  danger  is  a  great  one,  but  a  knowledge  of  radiology  would  be 
required  and  that  could  only  be  acquired  by  those  who  made  a 
profound  technical  study  of  the  subject.  The  application  of 
sufficient  exposures  to  the  ovary  in  order  to  secure  an  atrophy  of 
the  corpora  lutea  would  also  demand  some  special  means  to 

1  From  o^Xrj,  cicattix,  and  ir\afffftiv,  to  form. 


ELECTROTHERAPY  81 

correct  the  effects  produced  on  the  tissues  intervening  between 
the  skin  and  the  ovaries. 

Indications. — With  a  knowledge  of  these  elements  of  physics 
and  physiology,  we  will  be  able  to  grasp  the  principles  of  elec- 
trical treatment.  In  the  first  place  we  will  study  the  functional 
troubles ;  in  the  second  place,  the  organic  troubles  of  the  genital 
tract. 

Functional  Troubles. — In  vaginal  applications  the  continuous 
current  has  been  successfully  employed  in  amenorrhea  combined 
with  infantilism  and  aplasia  of  the  genital  organs.  A  dozen  or 
twenty  sittings,  bi-weekly,  lead  at  times  to  a  sufficient  modifica- 
tion in  the  nutrition  of  the  organs  afflicted  with  aplasia  as  to 
enable  them  to  recommence  their  functions. 

The  nervous  forms  of  amenorrhea  are  treated  with  static 
electricity.  Bouilly,  in  one  of  his  clinics,  has  especially  drawrn 
attention  to  the  role  that  static  electricity  may  play  in  favoring 
menstruation  or  to  stimulate  that  function  in  young  lymphatic 
girls  of  neuropathic  family  or  those  brought  up  in  defective 
hygienic  conditions. 

Nervous  dysmenorrhea  may  be  successfully  treated  in  the  same 
manner,  and,  above  all,  in  obstruction  by  stenosis  or  atresia  of 
the  cervix  that  the  efficacy  of  electrization  is  remarkable.  In 
such  a  case  the  flexibility  producing  action  of  the  pole  is  the  agent 
we  use.  The  electric  sclerosis  produced  by  intracervical  applica- 
tions of  the  negative  pole  is  best  done  with  Hegar's  dilators. 
The  gradually  .increasing  flexibility  of  the  cervical  tissue  will  ren- 
der its  dilatation  easy,  and  a  rigid  cervix  sclerosed  by  prolonged 
inflammation,  or  bound  down  by  cicatrices  will  become  trans- 
formed in  some  weeks  into  a  flexible  and  extensible  organ. 

It  is  a  rule  that,  from  the  first  menstruation  on,  the  pains, 
connected  with  the  stenosis,  become  more  or  less  greatly  reduced. 
This  lessening  becomes  more  and  more  marked  in  the  successive 
periods. 

By  its  simplicity,  ease  and  harmlessness  this  procedure  pre- 
sents strong  advantages  over  manipulations  aiming  at  the  auto- 
plastic  repair  of  an  orifice,  as  also  over  the  dilatation  with  Hegar's 
dilators  which  only  act  mechanically  and  do  not  alter  the  tissues. 

In  closing  this  chapter  on  the  functional  indications  of 
electricity,  I  would  like  to  draw  attention  to  the  astounding  rapid- 


82  PHYSICAL   AGENTS   IN    GYNECOLOGY 

ity  with  which  radiotherapy  and  the  high  frequency  current, 
singly  or  combined,  cause  the  disappearance  of  such  localized 
pruritus  as  the  vulvar  variety. 

Organic  Lesions. — When  Apostoli,  in  1884,  proposed  the 
continuous  current  of  a  high  intensity  for  the  cure  of  fibroma, 
gynecological  surgery  had  not  attained  to  that  perfection  that 
asepsis  and  operative  technic  have  since  given  it.  Statistics  of 
that  epoch  bear  witness  to  the  dangers  of  surgical  intervention ; 
it  is  not  then  surprising  that  such  a  mode  of  treatment  was 
received  with  favor,  a  palliative  one  it  is  true,  but  relatively 
harmless. 

To-day  Apostoli's  method  has  fallen  into  oblivion.  Some 
observers  have  entirely  discredited  it  as  it  was  thought  that  its 
introduction  might  be  a  rival  to  surgery.  Such  a  point  of  view 
is  entirely  wrong;  really,  the  electrical  treatment  of  fibromas  is 
only  an  auxiliary  role  in  such  cases  as  are  inoperable  or  where  an 
operative  contraindication  exists.  The  great  principle  "Every 
fibroma  producing  complications,  once  recognized,  should  be 
removed"  is  to-day  the  only  line  of  conduct  for  the  practitioner, 
and  it  is  only  in  cases  where,  for  some  particular  reason,  an  opera- 
tion cannot  be  carried  out  that  we  have  resource  to  the  palliative 
means  the  continuous  current  offers  us. 

Electrical  treatment,  therefore,  is  used  in  inoperable  cases 
(tubercular,  albuminuric  and  cardiac) ;  it  should  also  be  used  in 
cases  where  the  size  of  the  tumor  or  widely  extended  adhesions 
render  the  operative  treatment  impracticable.  Sometimes  the 
proximity  of  the  menopause  is  sufficient  reason  for  deferring 
surgical  intervention,  or  even  the  desire  of  a  young  woman  to 
become  a  mother.  In  such  cases  we  can  more  or  less  make  an 
attempt  at  electrization  in  order  to  combat  the  most  alarming 
symptoms  in  the  particular  case,  viz.,  hemorrhage.  It  is  not 
often  that  in  complications  of  this  kind  we  get  much  help  from 
electricity. 

There  are,  however,  circumstances  which  contraindicate  the 
employ  of  electricity;  they  are  diseased  adnexa  around  a  fibro- 
matous  uterus  (ovaro-salpingitis,  acute  or  purulent).  There  is 
no  need  to  lay  stress  on  the  dangers  that  electricity  may  cause  in 
such  conditions. 

The  operative  procedure  in  electrical  treatment  of  fibromata 


ELECTROTHERAPY  83 

is  quite  difficult  and  demands  much  technical  training.  The 
principal  part  of  the  operation  is  the  introduction  of  the  sound 
(which  is  made  of  platinum  or  carbon)  as  far  as  possible  into  the 
uterine  cavity.  The  passage  of  the  continuous  current  of  a 
strength  of  50  to  150  milliamperes,  according  to  the  amount 
tolerated,  and  finally  the  extraction  of  the  hysterometer.  Each 
sitting  should  last  about  8  to  10  minutes.  With  two  sittings  per 
week  the  electrical  treatment  of  a  fibroma  demands  from  two  to 
five  months. 

In  cases  where  the  sound  cannot  be  introduced,  for  instance 
in  those  cases  where  it  might  be  deemed  necessary  to  test  the 
patient's  susceptibility  beforehand,  the  intrauterine  applications 
are  replaced  by  vaginal  galvanization. 

It  is  difficult  a  priori  to  understand  the  action  on  the  fibroma ; 
but  we  must  not  forget  that  its  efficacy  is  purely  symptomatic, 
that  it  does  not  modify  the  volume  of  the  tumor,  as  has  been 
claimed,  but  that  it  diminishes  the  congestive  condition,  and  may 
thus  reduce  the  edema,  lessen  the  twitching  pains,  and  the  sensa- 
tion of  bearing-down  and  the  vesical  compression  and  at  times 
cause  complete  disappearance  of  the  hemorrhage. 

What  is  the  process  upon  which  this  hemostatic  action  depends? 

Apostoli  thought  it  was  a  specific  action  of  the  positive  pole,  a 
coagulating  action  combined  with  a  caustic  one,  leading  to  a 
mechanical  obliteration  by  the  formation  of  eschars.  However, 
this  hardly  explains  how  a  little  instrument  like  the  platinum  or 
carbon  sound  can  be  capable  of  exerting  its  influence  over  such 
an  area  as  the  internal  surface  of  a  myomatous  uterus.  Fredericq, 
to  whom  we  owe  importance  in  histology  on  the  alterations  en- 
gendered by  electrolysis,  declares  that  the  action  of  the  instru- 
ment, as  seen  under  the  microscope,  is  confined  to  hardly 
visible  points. 

We  have  proposed  in  our  thesis1  a  theory  of  the  action  of  the 
continuous  current,  quite  different  from  all  previous  ones  and 
based  on  physiological  experimentation.  Keiffer's  work  on 
uterine  physiology  has  rendered  clear  that  the  uterine  muscle  may 
be  considered  as  an  enormous  outgrowth  of  the  muscular  coat  of 
the  utero-ovarian  vessels. 

1  Zimmern,  Uterine  Hemorrhages,  Their  Electric  Treatment  and  Excito-motor  Action 
of  Electricity,  Paris,  1901,  Bailliere  et  Cie. 


84  PHYSICAL   AGENTS   IN   GYNECOLOGY 

It  is  known  that  the  middle  layer  of  the  uterine  muscle  fibers 
contains  some  vascular  lakes  limited  by  an  epithelial  layer  which 
rests  directly  on  the  muscle.  The  role  of  the  muscle  fiber  at  the 
moment  of  delivery  is  besides  well  known;  recall  for  a  moment 
the  classical  picture  of  "a  thousand  living  ligatures"  which  cut  off 
the  hemorrhage  and  now  there  is  no  doubt  that  the  uterine  muscle 
fiber  gradually  becomes  the  seat  of  very  active  peristaltic  move- 
ments, as  the  result  of  the  prolonged  passage  of  the  continuous 
current. 

The  fact  is  proved  by  the  colic  of  which  women  complain 
after  their  seance  of  electrization,  by  the  facility  with  which  one 
effects  the  formation  of  a  pedicle  in  submucous  fibromata  treated 
by  electrical  means  and  also  the  rapidity  of  their  expulsion.  On 
the  other  hand,  two  bitches  are  submitted  to  uterine  curetting, 
and  one  of  them  is  electrolized  while  the  other  is  kept  as  a  control ; 
if  at  the  end  of  forty-eight  hours  hysterectomy  is  performed  in 
both  cases,  the  control  case  is  found  to  have  an  abundant  hemor- 
rhagic  infiltration  throughout  the  mucous  and  submucous  tissues 
while  in  the  curetted  and  electrolized  case  the  vessels  appear  to  be 
empty  of  blood. 

The  result  of  observations  seems  to  be  that  by  its  excito-motor 
action  the  continuous  current  acts  on  the  muscular  fiber  of  the 
uterus.  Without  doubt  this  muscle  fiber  is  frequently  inhibited 
in  its  function  as  regulator  of  menstruation  by  the  presence  of 
the  obstruction  of  the  fibroma  or,  in  other  cases,  in  virtue  of 
Stoke's  law,  it  is  reduced  to  atony  by  inflammatory  troubles  of 
the  mucous  membrane,  which  coexist  so  frequently  with  fibro- 
mata. 

The  treatment  of  metritis  is  an  important  chapter  of  gyneco- 
logical electro-therapy. 

We  will  pass  over  false  metritis,  congestions  occurring  at  the 
menopause,  and  metritis  of  virgins  which  offer  to  the  electrical 
therapeutist  such  an  extended  field  of  action,  but  whose  number 
forces  us  to  pass  over  them  in  silence  in  this  survey. 

We  pass  now  to  the  true  metritis. 

The  continuous  current  in  chronic  metritis  has  given  such 
sufficiently  constant  and  lasting  results  that  this  method  of  treat- 
ment may  be  classed  among  the  best  of  minor  gynecology. 

Two  methods  lie  before  us,  viz.,  intrauterine  electrolysis  with 


ELECTROTHERAPY  85 

non-acid  corrosive  electrodes,  and  the  electrolytic  introduction  of 
certain  ions,  known  as  the  old  interstitial  electrolysis. 

The  technic  is  practically  analogous  to  that  which  we  briefly 
described  above  in  connection  with  fibroma.  The  vaginal  appli- 
cations, notwithstanding,  are  only  indicated  in  certain  cases  of 
hemorrhagic  metritis.  The  contraindications  resulting  from  the 
condition  of  the  adnexa  are  the  same  as  before.  Finally,  from 
the  point  of  view  of  the  intensity  of  current,  generally  one  em- 
ploys about  50  to  80  milliamperes,  exercising  discretion  of  course 
according  to  the  susceptibility  of  the  patient.  A  series  of  four  to 
twenty  sittings,  according  to  the  condition,  generally  causes  a 
cessation  of  the  pains,  of  the  hemorrhages,  and  of  the  leucorrhea. 

Apostoli  thought  that  the  development  of  acids  in  the  neigh- 
borhood of  the  positive  electrode  in  the  uterine  cavity  produced 
modifications  of  important  structures  in  the  mucous  membrane, 
and  even  led  to  its  replacement  by  new  tissue.  Further,  the  tonic 
action  exercised  by  the  continuous  current  on  the  muscular  fiber 
appears  to  Apostoli  as  particularly  apt  to  bring  about  contractility 
of  the  uterine  muscle  and  thus  fortunately  to  influence  the  circu- 
lation of  the  organ. 

This  excito-motor  action  on  the  uterine  muscle,  to  which  we 
give  a  preponderance  of  action  seeing  its  hemostatic  effects  on 
fibromata  has  perhaps,  equally,  from  the  standpoint  of  its  action 
in  metritis,  an  influence  greater  than  one  would  at  first  suspect. 
In  endometritis,  the  uterine  muscle  is  directly  or  indirectly  affected 
by  the  inflammatory  process.  It  is  highly  probable  the  return- 
ing activity  of  the  uterine  muscle  brings  about  important  circula- 
tory changes  in  the  organ,  consequently  improving  its  nutrition 
and  favoring  the  carrying  of  material  necessary  for  the  defence 
and  repair  of  the  anatomical  elements  of  the  diseased  mucous 
membrane. 

As  it  is  difficult  to  admit  that  the  entirety  of  the  uterine  cavity 
can  be  influenced  by  the  products  of  electrolysis,  still,  remember- 
ing that  intervals  elapse  between  the  sittings,  it  is  probable  that 
during  these  periods  some  portions  of  the  diseased  endometrium 
propagate  their  diseased  state  to  neighboring  areas  which  have 
since  become  healthy;  and  this  explains  why  metritis  affecting 
the  body  is  so  difficult  and  so  long  to  cure. 

The  conditions  are  not  the  same  in  cervical  endometritis. 


86  PHYSICAL   AGENTS   IN   GYNECOLOGY 

Here  the  sound  is  embraced  by  the  neck,  and  in  a  few  sittings 
the  effect  of  the  poles,  aided  by  diffusion,  is  evidenced  on  prac- 
tically the  whole  of  the  internal  cervical  surface.  As  is  well 
known,  an  old  metritis  tends  to  become  limited  to  the  cervix, 
and  as  the  majority  of  such  cases  come  to  the  electro-therapeutist, 
we  can  understand  the  action  of  electricity  in  the  cases  cured  by 
these  means. 

The  electrolytic  introduction  of  "ions"  into  the  substance  of 
the  uterine  mucous  membrane  merits  being  taken  into  considera- 
tion because,  with  the  exception  of  electrolysis,  there  are  no 
therapeutic  means  to  bring  about  the  certain  penetration  of  such 
an  active  substance  below  the  epithelial  surface. 

The  interstitial  electrolysis  of  silver  has  been  advocated  by 
Leduc,  Boisseau  and  Rocher.  The  zinc  ion  has  been  quite 
recently  advocated  by  Leduc  as  both  an  antiseptic  and  hemo- 
static  agent.  Attempts  have  also  been  made  with  copper  elec- 
trodes (Gautier),  iron  (Regnier),  and  aluminium  (Debedat),  but 
further  experience  has  not  justified  their  use.  The  strength  of 
current  used  with  these  electrodes  is  generally  quite  moderate. 
It  is  better  not  to  use  more  than  50  milliamperes.  Each  sitting 
should  last  from  6  to  10  minutes. 

From  the  foregoing  it  will  be  seen  that  the  electrolytic  proce- 
dures we  use  in  the  treatment  of  metritis  are  four  in  number; 
simple  intrauterine  electrolysis  where  the  positive  or  negative  pole 
is  actually  employed  according  to  the  effect  desired,  and  the 
electrolytic  introduction  of  either  the  silver  or  zinc  ion.  Let  us 
now  consider  in  which  circumstances  we  would  employ  either  the 
one  or  the  other. 

It  is  a  rule  to  use  positive  electrolysis  when  the  metritis  is 
complicated  with  menorrhagia  or  metrorrhagia.  In  such  condi- 
tions we  are  probably  dealing  with  a  corporal  metritis.  In  addi- 
tion, with  the  purpose  of  obtaining  the  caustic  action  on  the 
greatest  possible  surface  of  the  uterine  mucous  membrane,  it  will 
be  found  most  useful  to  use  carbon  electrodes,  choosing  the 
largest  size  one  can  conveniently  introduce. 

The  use  of  carbon  is  particularly  to  be  recommended  in 
old  metritis  and  fungoid  metritis,  where  the  hemorrhagic  losses 
are  combined  with  vegetations  on  the  surface  of  mucous  mem- 


ELECTROTHERAPY  87 

brane.  Where  the  positive  electrolysis  fails,  the  indication  is  to 
try  the  zinc  ion. 

When  the  metritis  is  accompanied  by  menorrhagia  only,  a 
condition  of  atony  of  the  uterine  muscle  is  generally  found  too 
and  if  the  tonicity  of  the  muscle  is  restored,  the  hemorrhage 
ceases.  A  few  vaginal  applications,  utilizing  the  excito-motor 
power  of  the  current  only,  will  be  found  sufficient. 

In  metritis  where  the  main  feature  is  leucorrhea,  we  should 
use  electrolysis  with  silver  or  the  negative  pole.  The  former 
seems  to  exercise  quite  a  special  action  in  metritis  of  gonococcal 
origin,  either  at  the  beginning  or  in  the  chronic  state.  One  can 
almost  always  obtain  very  rapid  results  in  these  cases.  Similar 
results  are  obtained  after  the  use  of  the  salts  of  the  same  metal  in 
other  manifestations  of  gonococcal  origin,  such  as  conjunctivitis, 
cystitis,  etc.  Silver  electrolysis  ceases,  however,  to  be  efficacious 
when  the  gonococcal  metritis  becomes  very  chronic. 

In  the  majority  of  chronic  metrites  limited  to  the  cervix,  in 
women  who  have  had  whites  for  a  number  of  years,  and  particu- 
larly in  those  cases  of  irritative  hypersecretion  of  the  cervix, 
following  infection,  negative  electrolysis  is  the  procedure  of  choice. 
The  results  obtained  under  these  conditions  are,  without  doubt, 
due  for  the  most  part,  to  the  electrolytic  caustic  action,  penetrat- 
ing the  cervical  mucous  membrane  deeply.  These  are  therefore, 
in  brief,  the  indications  for  electrical  treatment  in  cases  of  chronic 
metritis. 

It  is  easy  to  understand  by  reason  of  the  physiological  effects 
of  the  current  that  uterine  subinvolution  may  be  considered  a 
case  for  electricity.  The  specific  action  of  the  continuous 
current  on  the  smooth  uterine  muscle  fiber  is  sufficient  to  render 
this  treatment  as  the  best  in  conditions  of  involution  following 
on  an  accouchement  or  on  an  abortion  uncomplicated  by  sepsis. 

Quite  recently  a  case  of  partial  subinvolution  came  under 
our  notice  which,  from  the  standpoint  of  our  statement  above, 
seems  very  instructive.  The  case  was  a  girl  who  after  a  pro- 
cured abortion  began  to  suffer  from  extremely  abundant  hemor- 
rhage. The  temperature  was  normal,  but  the  patient  became 
daily  weaker.  Her  medical  attendant,  an  eminent  gynecologist, 
having  tried  douches,  decided  to  curette  her. 

This  did  not  give  the  desired  result.     The  tamponing  was 


88  PHYSICAL  AGENTS   IN    GYNECOLOGY 

continued,  as  also  the  astringent  applications  and  ergotine  in- 
ternally. The  hemorrhage  continued  and  I  was  sent  for.  Her 
uterus  on  palpation  gave  me  an  impression  of  peculiar  relaxation 
and  softness,  and  laterally,  in  the  region  of  the  right  cornu,  my 
finger  outlined  a  very  depressible  sort  of  ampullary  dilatation. 
After  the  second  application  of  intrauterine  electrolysis  the  flux 
diminished  by  at  least  one-half  and  palpation  enabled  me  still  to 
recognize  the  subinvoluted  portion,  but  very  markedly  dimin- 
ished in  size. 

After  the  sixth  application,  about  ten  days  after  the  electrical 
treatment,  the  hemorrhages  had  completely  ceased  and  the  uterus 
had  reassumed  its  normal  shape. 

I  have  reported  this  case,  but  all  cases  of  subinvolution  treated 
by  electricity  react  in  a  similar  manner. 

All  that  now  remains  is  to  consider  the  indications  of  electricity 
in  the  treatment  of  neoplasms  of  the  genitourinary  tracts.  Unfor- 
tunately, the  services  it  can  render  in  this  field  are  palliative  only 
and  the  hopes  that  two  new  methods,  radiotherapy  and  fulguration, 
have  engendered  in  the  last  few  years,  have  in  a  great  measure 
declined.  Without  doubt,  it  is  possible,  with  special  localizing 
to  instruments  such  as  speculums  to  irradiate  a  cervical  neo- 
plasm through  the  , vagina  and  we  are  also  enabled  with  very 
penetrating  rays  and  by  the  procedure  known  as  "feu  croise" 
to  irradiate  a  uterine  neoplasm.  This  method,  however,  which 
might  be  efficacious  if  applied  early,  when  the  neoplasm  is 
limited,  loses  all  its  curative  value  if  an  early  diagnosis  is  not 
made.  The  same  may  be  said  of  fulguration,  that  is,  a  surgical 
curetting  followed  by  a  prolonged  application  of  the  electric 
spark  to  the  resulting  wound.  There  is  no  case  of  cure  of  a  uter- 
ine neoplasm  by  the  electric  spark.  Its  only  benefit  lies  in  the 
possibility  of  lessening  for  a  time  the  pain  and  fetid  discharges 
and  of  rescuing  the  poor  sufferer  temporarily  from  being  an  ob- 
ject of  repulsion  to  her  entourage.  In  contradistinction,  the  vul- 
var  epithelioma,  when  limited  and  superficial,  is  a  splendid  case 
for  radiotherapy  and  fulguration. 

2.  Kinetotherapy. 

Kinetotherapy,  or  the  therapy  of  movements,  has  been  applied 
as  treatment  in  gynecological  affections  by  Thure  Brandt. 


KINETOTHERAPY  89 

Popularized  in  Germany  by  Schultze  and  his  pupils,  Stapfer1 
has  been  its  main  advocate  in  France,  from  whose  works  we 
will  borrow  the  main  portion  of  that  which  now  follows. 

In  gynecology,  more  than  for  any  other  class  of  complaint, 
the  fundamental  precept  of  kinetotherapy  is  to  observe  great 
gentleness  in  the  different  manipulations  which  constitute  this 
method  of  treatment. 

The  patient  should  suffer  only  in  exceptional  circumstances 
during  the  sitting;  she  ought  never  to  suffer  afterward  but  should, 
on  the  contrary,  feel  immediately  a  sense  of  well-being. 

Gynecological  kinetotherapy  should  comprise  two  kinds  of 
manipulation : 

1.  Movements  of  massage  in  the  true  sense. 

2.  The  execution  of  particular  movements. 

Massage.- — The  principal  manipulations  of  massage  are  the 
following,  according  to  Stapfer: 

1.  Circular  Friction. — The  left  index-finger  having  been  intro- 
duced into  the  vagina2  in  order  to  support  the  organs  and  to  guide 
the  movements  of  the  external  hand,  with  the  right  hand  circu- 
latory friction  lightly  pressing  on  the  viscera  which  are  made  to 
roll  under  the  fingers. 

2.  Vibration. — This  consists  in  a  rapid  vibratory  movement 
produced  by  the  palm  of  the  left  hand  placed  flat  on  the  lower 
part  of  the  abdomen. 

3.  Pressure. — Circulatory  friction  is  accompanied  by  a  certain 
degree  of  pressure.     The  corrective  pressure  is  made  by  intro- 
ducing four  fingers  of  the  right  hand  between  the  pubis  and  the 
anterior  surface  of  the  uterus,  so  as  to  exercise  pressure  at  the 
fundus  of  the  anterior  fornix. 

4.  Elevation. — This  consists  in  plunging  both  hands  open  into 
the    utero-vesical    pouch    through    the    abdominal  wall  and   to 
depress  the  peritoneal  cul-de-sac  and  the  anterior  fornix  of  the 
vagina  in  such  a  way  as  first,  to  cause  the  recession  and  then  the 
remounting  of  the  cervix  into  the  sacral  concavity;  second,  to 

1  Stapfer  (H.),  Treatise  of  Kinetotherapy,  Paris,  1897,  and  Gynecological    Kineto- 
therapy, Paris,  1899.     Consult  also,  Jentzer  and  Bourcart,  Gynecological   Gymnastics 
and  Manual  Treatment  of  Uterine  Maladies  and  of  the  Adnexa,  Paris,  1891. 

2  Stapfer,  in  accordance  with  Brandt,  insists  that  in  order  to  employ  the  index-finger 
to  its  full  usefulness,  it  is  unnecessary  to  flex  the  other  three  fingers  into  the  palm. 
Maintain  them  extended  slightly  flexed  at  the  metacarpophalangeal  joint,  which  permits 
the  index  to  go  in  as  far  as  the  digito-palmar  fold  which  rests  against  the  perineunvT 
Otherwise  the  same  as  for  vaginal  examination. 


90 


PHYSICAL   AGENTS   IN    GYNECOLOGY 


antevert  the  fundus;  third,  to  lightly  raise  the  whole  organ  by 
a  gentle  vibratory  movement. 

5.  Stroking. — This  is  performed  per  rectum;  on  the  pelvic 
walls,  the  perineum  and  recto-uterine  folds,  and  the  pouch  of 
Douglas.     It  is  done  with  the  pulp  of  the  index-finger  which 
strokes  the  tissues  without  more  force  than  would  be  expended 
in  writing  on  a  window  coated  with  mist. 

6.  Malaxation  or  Kneading. — This  is  an  external  manipula- 
tion performed  with  both  hands,  which  are  made  to  grasp  the 


FIG.  79. — The  patient  is  seated 
and  inclined  forward.  The  arms 
are  extended  in  the  line  of  inclina- 
tion of  the  trunk.  The  elbows  are 
carried  backward  and  outward  as 
far  as  possible,  while  the  masseur 
gently  endeavors  to  oppose  these 
movements  and  then  brings  the 
arms  without  resistance  from  the 
patient's  part  back  to  the  position 
of  extension 


FIG.  80. — The  patient  lies  in  the  extended 
position  with  the  pelvis  slightly  raised  and 
the  legs  and  hips  flexed.  She  separates  the 
thighs  while  the  masseur,  with  hands  on  the 
external  surface  of  the  knees  resists  this  move- 
ment. Then  the  masseur  gently  brings  the 
knees  in  toward  the  middle  line  and  the  pa- 
tient endeavors  to  oppose  him. 


subcutaneous  adipose  tissue  and  convert  it  into  folds,  which  are 
then  kneaded  between  the  thumbs  and  the  four  other  fingers, 
while  the  skin  is  stretched. 

Movements. — Movements  are  of  three  kinds:  1.  movements 
which  lessen  pelvic  congestion;  2.  movements  which  increase 
pelvic  congestion;  3.  respiratory  movements. 

1.  Movements  Lessening  Congestion. — These  are  the  move- 
ments of  flexion  and  extension  of  the  arms  and  their  action  on 


KINETOTHERAPY 


91 


thighs. 


the   trunk   and   also   movements    of   abduction    of   the 
These  are  opposed  by  the  doctor  (Figs.  79  and  80). 

2.  Movements    Increasing   Congestion. — These    are    passive 
movements  of  femoral  circumduction  and  extension  and  flexion 


FIG.  81. — The  patient  is  in  the  half  sitting 
position.  The  masseur  flexes  the  leg  and  the 
thigh  and  then  circumducts  from  within  out- 
ward at  the  hip-joint.  The  patient  remains 
passive,  the  other  leg  being  held  by  an  assis- 
tant. 


FIG.  82.— Flexion  and 
extension  of  the  knee  on 
each  foot  alternately.  The 
arms  are  raised  above  the 
head,  and  the  other  foot 
placed  posteriorly  acts  as 
a  support. 


of  one  of  the  legs  which  supports  the  weight  of  the  body.  The 
former  give  rise  to  a  temporary  obstacle  to  the  peripheral  circu- 
lation and  the  latter  lead  to  a  tension  of  the  abdominal  wall 
which  in  turn  compresses  the  viscera  (Figs.  81  and  82). 

3.  Respiratory  Movements. — The  doctor,  standing  behind  the 
patient,  raises  the  shoulders  and  arms  wrhile  the  patient  inspires 
deeply.  Then  he  allows  the  shoulders  to  descend  during  expi- 
ration (Fig.  83).  These  respiratory  movements  are  important 
in  that  they  stimulate  combustion,  increase  the  respiratory  field, 
and  by  the  action  of  the  diaphragm,  cause  the  elasticity  of  the 
suspensory  apparatus  to  come  into  play  and  that  of  the  abdominal 
pelvic  vessels. 

In  practice,  at  the  same  sitting,  are  combined  massage  and 
movements. 

The  patient  without  disrobing  loosens  the  strings  of  her 
skirt  and  unbuttons  her  corsets  in  such  a  way  as  to  leave  nothing 


92 


PHYSICAL  AGENTS   IN   GYNECOLOGY 


to  interfere  with  respiration,   which  should  always  be  regular 
and  full  during  the  gymnastic  movements  and  the  massage. 

If  we  take  as  the  most  common  type  a  case  of  old  exudates, 
the  sitting  should  commence  with  movements  to  lessen  congestion. 
Then  if  the  patient  is  extended,  on  a  long  couch,  with  the  thighs 
flexed  on  the  pelvis  and  the  legs  on  the  thighs,  the  masseur 
should  commence  with  semicircular  friction  and 
vibratory  movements  round  about  the  uterus 
and  adnexa,  being  careful  not  to  squeeze  the 
organs. 

This  massage,  which  ought  not  to  last  more 
than  five  minutes,  is  followed  by  movements 
lessening  congestion.  The  sitting  is  terminated 
by  passive  respiratory  exercises,  followed  by  a 
rapidly  executed  vibration  with  the  palm  of  the 
hand  passed  along  the  whole  length  of  the  verte- 
bral column. 

These  exercises,  etc.,  are  continued  daily  even 
during  menstruation. 

The  action  of  these  different  manipulations 
FIG.  83. — The  is  two-fold.  Locally,  they  increase  the  elasticity 
ctast6Ubyaidrawing  of  the  agents  which  fix  the  uterus  and  they 
wardandUlbackwa?d  nDerate  the  organs  by  relaxing  their  attachments. 
while  the  patient  in-  They  lead  to  a  reabsorption  of  plastic  products, 

spires  deeply.  •        •        i  •  •  i 

and  stimulate  the  nutrition  ot  the  viscera. 

They  also  improve  the  general  state  by  stimulating  the 
circulation  and  diminishing  constipation.  Some  authors  find 
that  they  augment  the  muscular  tone  of  the  cardiac  muscle  in 
that  they  provoke  cardio-vascular  reflexes. 

Indications  and  Contraindications. — The  indications  of  kineto- 
therapy  seem  limited.  They  would  seem  to  us  to  be  reserved  to 
cases  of  women  suffering  from  long-standing  remnants  of  peri- 
uterine  inflammation,  which  has  remained  long  quiescent  and 
above  all  associated  with  a  certain  amount  of  visceral  ptosis 
(slight  uterine  prolapse,  enteroptosis  or  movable  kidney).  In 
these  cases,  the  slight  degree  of  gravity  of  the  troubles,  their 
multiplicity,  and  the  atony  of  the  tissues  contraindicate  surgical 
intervention.  Further,  such  cases  are  common  in  women  of  a 
neuropathic  temperament,  where  operative  benefit  is  more  or 


HYDROTHERAPY  93 

less  illusory  and  where  they  have  much  to  gain  through  the 
kkjetotherapeutic  measures  to  which  one  might  be  tempted  to 
add  hydrotherapy. 

Again,  in  certain  \vomen  suffering  from  abdominal  trouble, 
with  constipation  and  insufficient  intestinal  circulation,  massage, 
combined  with  gymnastic  exercises,  is  useful,  as  the  abdominal 
muscles  are  brought  into  play. 

Massage  is  contraindicated  in  inflammatory  lesions,  not 
entirely  quiescent  in  which  manipulations  might  lead  to  their 
rejuvenescence.  In  cases  of  recent  hemorrhages  or  of  purulent 
periuterine  collections,  disastrous  consequences  may  be  induced 
and  in  such  cases  it  is  rigidly  contraindicated. 

Sismotherapy.1 — Sismotherapy,  which  consists  in  giving  rapid  and 
regular  vibrations  of  small  amplitude  during  a  brief  period,  has  been  studied 
by  Jayle. 

With  the  aid  of  an  electric  motor  and  a  flexible  connective  rod  he  im- 
parts to  a  little  apparatus  of  varied  shapes,  called  a  "concuteur,"  a 
vibratory  movement. 

It  would  appear  to  be  a  means  of  combating  gastrointestinal  atony  and 
particularly  cases  of  nervous  women  or  neuroarthritics  of  minor  degree,  or 
finally  pain  where  our  usual  therapeutic  means  are  unsuccessful. 

3.  Hydrotherapy. 

We  have  already  had  occasion  to  study  vaginal  injections. 
Generally  speaking,  hot  water  is  most  used,  but  luke-warm  for 
prolonged  irrigation  and  under  low  pressure  may  be  used  for 
its  sedative  effect. 

Reclus  has  become  the  apostle  of  hot  rectal  irrigation  in  order 
to  combat  the  congestion  of  the  pelvic  organs. 

Douches,  general  or  local,  render  useful  service  as  also  do  hot 
moist  abdominal  compresses.  Cold  water  compresses  are  also 
useful.  If  a  sedative  effect  is  desired,  we  use  chlorinated 
magnesium  waters  (Salies,  Biarritz) ;  if  a  stimulating  effect, 
waters  from  Salins-du-Jura  or  Kreuznach.  In  very  acute 
phlegmasia,  the  continuous  application  of  an  ice-bag  to  the 
abdomen  is  of  signal  service. 

1  Jayle  and  De  Lacrpix  de  Lavallette,  Mechanical  Sismotherapy  in  Gynecology, 
Revue  de  Gynecologic,  Paris,  1899,  p.  645.  Boucart,  Treatment  of  Uterine  Affections  and 
of  the  Adnexa  by  Mechanical  and  Rapid  Vibrations,  Ann.  de  Gynec.,  Paris,  1895,  T.  L, 
p.  476. 


94  PHYSICAL   AGENTS   IN   GYNECOLOGY 

It  seems  unnecessary  to  dwell  more  on  these  points,  which  are 
not  particularly  in  our  gynecological  domain. 

Let  us  add  that  baths  combined  with  hot  vaginal  irrigations, 
general  douches,  either  hot  or -Scotch,  and  finally  local  peri- 
gastric  douches  render  great  service  in  helping  reabsorption  of 
old  exudates  and  in  diminishing  those  painful  complications  of 
which  a  certain  number  of  women  complain,  and  which  we 
will  now  describe.  Such  cases  are  found  to  be  suffering  from 
dysmenorrhea  with  abundant  menstrual  flow,  whites,  globular 
uterus,  sclero-cystic  ovaries  and  painful  chronic  metritis,  a  series 
of  complaints  wrhich  Richelot,  for  want  of  a  better  term,  has 
described  under  the  name  neuro-arthritic  uterine  sclerosis,  a 
nomenclature  undoubtedly  erroneous,  but  enabling  us  to  group 
practically  under  one  heading  those  particular  cases  for  whom 
operative  treatment  is  generally  advised  and  for  whom  it  presents 
practically  no  utility.1 

4.  Hydromineral  Treatment. 

This  aspect  of  gynecological  treatment  is  too  much  perhaps 
neglected  by  a  certain  number  of  gynecologists,  who  only  see 
treatment  from  the  operative  point  of  view.  However,  hydro- 
mineral  treatment  is  an  important  adjuvant  to  ordinary  thera- 
peutic measures. 

While  actually  this  form  of  treatment  does  not  yet  rest  on  a 
scientific  base,  the  information  acquired  by  empiric  measures 
permits  us  to  afford  very  useful  indications  for  its  use  to  patients. 

The  Principal  Waters  Used  in  Gynecology. 

A.  Robin  and  Dalche2  have  shown  the  action  of  different 
groups  of  mineral  waters  to  which  the  gynecologist  has  resource. 
We  will  borrow  from  their  work  the  major  part  of  the  following 
text. 

Chlorinated  Soda  Waters. — These  waters  are  divided  into 
those  of  feeble  action  (Bourbon-Lancy,  Bourbon-l'Archambault, 
Saint-Nectaire,  la  Motte-les-Bains,  Bourbonne,  Santenay,  etc.,  in 

1  Richelot  (L.  G.),  On  the  Treatment  of  Pelvic  Affections.     La  Gynecologic,  Paris, 
May,  1909,  p.  193. 

2  Albert  Robin  and  Paul  Dalche,  Medical  Treatment  of  Diseases  of  Women,  Paris, 
1902. 


HYDROMINERAL  TREATMENT  95 

France ;  Baden-Baden,  Wiesbaden,  Kissingen,  abroad) ;  moderate 
action  (Balaruc,  Salies  en  Haute-Garonne,  Salins-du-Jura,  etc.,  in 
France;  Kreuznach,  Hombourg,  Nauheim,  Bex,  etc.,  abroad)  ;and 
strong  action  (Salies-de-Bearn,  Briscous-Biarritz,  La  Mouillere, 
etc.,  in  France;  Rheinfelden  abroad). 

They  produce  in  the  pelvic  organs  an  inflammatory  action 
characterized  by  a  reawakening  of  pain,  an  increase  in  the  secre- 
tions, and  stimulate  the  vitality  of  the  organs.  By  stimulating 
the  circulation  these  waters  lead  to  a  reabsorption  of  old  exudates. 

By  adding  the  mother  waters  to  baths  feebly  saline,  the  local 
and  general  reactions  are  reduced  in  order  to  bring  about  com- 
paratively Jthe  properties  tending  toward  resolution  of  the  saline 
bath  on  the  local  state.1 

Sulphurous  Waters. — These  waters  are  generally  noted  for 
their  excito-motor  and  hemostatic  actions  on  the  uterus. 
Certain  differences  exist  according  to  the  different  origins  of 
the  water.  While  certain  ones  are  purely  excito-motor  (Cau- 
terets,  Luchon,  etc.),  others  have  a  sedative  action  on  the 
nervous  system  (Saint-Sauveur,  Saint  Honore). 

Waters  Feebly  Mineral. — These  waters  generally  possess 
sedative  properties;  Neris  would  appear  to  suit  the  nervous 
uterine  patient  who  must  submit  to  a  treatment  of  prolonged 
bathing;  Luxeuil,  those  who  suffer  from  old  standing  remnants 
of  uterine  and  peri-uterine  inflammations,  as  also  those  who 
complain  of  a  multiple  symptomatic  complexus,  consisting  of 
excessive  irritability  of  the  nervous  system,  whites,  anemia  and 
constipation.  The  treatment  here  consists  in  more  or  less  pro- 
longed baths,  combined  writh  hot  vaginal  irrigations,  ascending 
douches,  and  lumbar  and  hypogastric  douches. 

Mud  Baths. — Mud  baths  assist  the  subinvolution  of  the  uterus 
and  are  found  at  Dax,  Saint  Amand,  Franzensbad,  Marienbad, 
Battaglia,  etc. 

Other  waters,  while  seemingly  having  no  direct  action  on  the 
uterus,  may  be  useful  in  modifying  the  general  condition  or 

1  The  mother  water  is  the  yellowish,  syrupy  liquid  which  remains  after  the  evapora- 
tion of  chlorinated  waters,  from  which  has  been  extracted  the  ordinary  commercial 
sea  salt;  it  is,  in  short,  intensely  concentrated  chlorinated  water  in  which  the  relative 
proportion  of  chloride  of  sodium  is  very  diminished.  The  sedative  action  of  this  mother- 
water  is  above  all  others  most  evident  in  the  waters  and  Salies-de-Bearn  and  of  Briscous- 
Biarritz,  which  are  very  rich  in  chloride  of  magnesium,  while  the  waters  of  Nauheim  and 
Kreuznach  are  noted  more  for  their  chloride  of  calcium  elements  and  those  of  Rheinfelden 
which  contain  hardly  any  chloride  of  sodium. 


96  ,  PHYSICAL   AGENTS   IN   GYNECOLOGY 

certain  neighboring  lesions  which  prevent  the  cure  of  the  genital 
trouble.  The  soda  bicarbonate  waters  (Vichy,  Vals,  etc.)  are 
useful  in  women  with  herpetic  or  gastrointestinal  troubles, 
bicarbonates  mixed  with  chlorinated  bicarbonates  (Royat,  Ems, 
St.  Nectaire)  in  anemic  cases  and  in  arthritic  cases,  the  waters 
of  the  type  of  Chatel-Guyon  for  constipated  cases  with  intestinal 
plethora,  the  iron  waters  (Forges,  Bussang,  Spa,  etc.)  in  chlorotic 
cases,  unless  we  are  dealing  with  a  nervous  and  erethetical  uterus, 
and  arsenical  waters  (La  Bourboule)  in  lymphatic  cases.  Baths 
of  carbonic  acid  (Royat  and  St.  Nectaire)  are  certainly  congestive 
and  may  render  useful  service  in  amenorrhea. 

Therapeutic  Indication  of  Mineral  Waters. 

Amenorrhea,  when  associated  with  chlorosis,  is  an  indication 
for  ferruginous  waters ;  if  the  temperament  is  the  lymphatic  type, 
saline  waters  are  useful;  if  leucorrhea  also  coexists,  sulphurous 
waters  are  indicated.  The  amenorrhea  of  stout  subjects  would 
first  be  treated  by  an  anti-obesity  regime  (Brides,  Chatel-Guyon, 
Marienbad),  that  of  nervous  origin  by  chlorinated  soda  waters, 
tempered  by  the  addition  of  the  afore  mentioned  mother  waters 
or  by  sedative  waters  (Neris,  Luxeuil,  etc.).  In  case  of  subin- 
volution  of  the  uterus  sulphurous  waters  are  suitable  (Cauterets, 
Saint  Sauveur)  or  mud  baths. 

Dysmenorrhea  has  the  same  indications. 

Congestive  metrorrhagia  of  puberty  will  obtain  great  benefit  by 
a  season  at  a  sodium  chloride  spa;  above  all,  in  young  girls  who 
are  very  nervous,  great  advantages  accrue  from  treatment  with 
baths  of  feeble  concentration  mixed  with  an  appropriate  quantity 
of  mother  waters. 

Metrorrhagia  occurring  at  the  menopause  is  well  treated  by  a 
course  of  baths  at  Bourbon-Lancy  if  there  coexists  an  arterial 
hypertension;  at  Chatel-Guyon,  at  Brides,  and  at  Saint 
Gervais,  if  there  is  also  abdominal  plethora. 

Catarrhal  metritis  should  be  treated  with  sulphurous  waters 
and  if  this  coexists  with  lymphatic  manifestations,  strong  sodium 
chloride  waters.  For  chronic  and  painful  genital  conditions,  and 
for  old  inflammatory  deposits,  waters  of  indifferent  character  or 
slightly  mineral  are  of  use. 


HYDROMINERAL  TREATMENT  97 

The  action  of  sodium  chloride  waters  on  fibromas  is  undeni- 
able ;  their  employ  is  however  contraindicated  in  cases  complicated 
with  cardiac  troubles  or  fatty  heart. 

To  combat  sterility  most  varied  are  the  different  waters 
suggested  and  good  results  which  have  been  attained  have 
resulted  more  probably  from  the  hygiene  observed  than  from 
any  special  action  of  the  waters. 

In  a  general  wray,  hygiene  and  regime,  well  observed,  are 
powerful  adjuvants  to  hydromineral  treatment. 


PART  II. 

TECHNIC  OF  OPERATIONS  ON  THE  VULVA,  VAGINA, 
UTERUS  AND  ADNEXA. 

CHAPTER  I. 

SURGERY  OF  THE  VULVA. 

Summary. — Anatomical  elements. — Treatment  of  traumatic  lesions 
(wounds  and  contusions). — Treatment  of  inflammatory  lesions  (superficial 
and  deep),  of  kraurosis,  leucoplasia,  and  pruritus  vulvse. — Operations  on 
the  vulva,  diminishing  it  (infibulation,  episiorrhaphy,  nymphorrhaphy), 
increasing  it  (treatment  of  agglutination  of  the  labia,  of  strictures,  and  of 
vulvo-vaginal  constriction). — Radical  operations,  excision  of  the  clitoris,  of 
inflammatory  lesions,  and  of  tumors  (benign  and  malignant). — Treatment 
of  vaginismus. 

1.  Elements  of  Anatomy. 

The  vulva  presents  the  form  of  a  median  antero-posterior 
cleft,  bordered  on  the  right  and  left  by  two  projecting  pads, 
the  labia  majora.  When  these  are  separated,  two  smaller  folds 
are  seen,  the  labia  minora,  which  anteriorly  embrace  the  clitoris 
and  in  the  space  between  them  is  found  the  vaginal  orifice  con- 
taining the  hymen  or  its  remains  and  the  urethral  orifice. 

Under  the  name  of  fourchette  is  understood  the  posterior 
commissure  of  the  vulva.  The  vestibule  is  the  small  triangular 
area  bounded  anteriorly  by  the  clitoris,  laterally  by  the  labia 
minora,  and  behind  by  the  meatus  urinarius.  Anterior  to  the 
fourchette  separating  it  from  the  vaginal  orifice  a  small  depression 
can  be  seen  which  is  known  as  the  fossa  navicularis. 

The  vulva  is  separated  from  deeply  lying  structures  by  the 
urogenital  diaphragm,  which  is  perforated  by  the  urethra  and  by 
the  vagina,  and  contains,  in  its  thickness,  the  deep  transversus 

98 


ELEMENTS  OF  ANATOMY  99 

muscle  and  branches  of  the  ischio-pubic  vessels  and  nerves, 
the  internal  pudic  artery  with  veins  and  accompanying  nerves. 
In  the  substance  of  the  posterior  portion  of  the  labia  majora 
are  the  vulvo-vaginal  glands  of  Bartholin,  whose  excretory 
canals  open  -on  the  groove  which  divides  the  labia  minora  from 


FIG.   84. — Vulva  of  a   virgin.     In    the    dissected    area   the   communications  of  Bar- 
tholin's  gland  with  the  bulb  and  the  muscles  which  cover  it  externally  are  well  seen. 

the  hymen  at  the  junction  of  the  posterior  third  with  the  anterior 
two  thirds  of  this  groove. 

Externally  and  anteriorly  to  the  vulvo-vaginal  glands  is  the 
bulb  of  the  vulva,  wrongly  termed  the  bulb  of  the  vagina 
because  it  is  situated  below  the  urogenital  diaphragm.  This 
bulb  of  the  vulva,  which  has  the  form  of  a  leech  gorged 


100 


SURGERY   OF   THE    VULVA 


with  blood  and  with  its  small  extremity  in  front,  is  covered  over 
by  the  bulbo-cavernous  muscle  or  constrictor  of  the  vulva. 

In  the  fatty  mass  which  constitutes  the  greater  part  of  the 
labia  majora  are  found  some  fibrous  tracts,  the  termination  of 
the  round  ligament,  and  sometimes  a  prolongation  of  peritoneum 
known  under  the  name  of  the  canal  of  Nuck. 


FIG.  85. — Vertical  and  transverse  section  of  the  pelvis  (after  Farabeuf). 
The  urogenital  diaphragm  D  with  the  vessels  and  nerves  it  contains  is  white.   Above 
it  are  the  deeper  lying  organs:  V,  vagina;  U,  uterus;  R,  levator  ani;  O,  obturator  inter- 
nus.  Below  it  are  the  vulva:  C,  corpus  cavernosum  of  the  clitoris;  B,  bulb  of  the  vulva; 
P,  section  of  pubes. 

The  vessels  of  the  labia  majora,  above  all  the  veins,  are 
very  numerous.  The  arteries  come  from  the  internal  pudic, 
which  gives  two  collateral  branches,  the  superficial  perineal 
which  ramifies  in  the  subcutaneous  cellular  tissue,  the  deep 
perineal  or  bulbar,  which  goes  to  the  bulb  of  the  vulva;  and 
two  terminal  branches,  the  cavernous  artery  which  goes  to  the 


TREATMENT  OF  TRAUMA  TO  THE   VULVA  101 

corpus  cavernosum  of  the  clitoris,  and  the  dorsal  which  goes 
to  the  surface  of  this  organ. 

The  veins  correspond  more  or  less  to  the  arteries ;  they  anas- 
tomose with  the  plexus  of  Santorini  and  with  branches  of  the 
internal  sapKenous.  They  often  dilate  during  pregnancy. 

The  lymphatics  go  to  the  inguinal  glands. 

The  nerves  come  from  the  internal  pudic. 

2.  Treatment  of  Trauma  to  the  Vulva. 
1.    Treatment  of  Wounds  of  the  Vulva. 

In  principle,  every  wound  of  the  vulva  should  be  reunited, 
an  immediate  union  having  in  this  region  a  threefold  object. 

1.  To   produce   a   condition   of   hemostasis,    because   small 
wounds  may  give  rise  to  quite  dangerous  hemorrhages.1 

2.  To  prevent  secondary  infection  which  may  easily  occur  in 
a  region  w^here  permanent  asepsis  is  impossible. 

3.  To  avoid  in  the  future  the  formation  of  faulty  cicatrices, 
which  may  deform  or  constrict  the  vulvar  orifice. 

Union  is  not  ahvays  possible  in  wounds  of  the  vulva.  It  is 
contraindicated  in  infected  wounds.  It  is  sometimes  impossible 
by  reason  of  the  size  of  the  wound.  It  is  important  in  such  a 
case  to  closely  examine  the  cicatrization. 

Burns  of  the  vulva  and  loss  of  substance  following  on  acute 
inflammations  of  the  region  (noma,  confluent  pustules  of  variola, 
etc.)  demand  special  attention.  Very  often  grafts  or  secondary 
autoplastic  operations  are  indicated  in  order  to  assist  as  much 
as  possible  the  cosmetic  and  functional  processes  of  the  reparation. 

2.  Treatment  of  Contusions  of  the  Vulva. 

The  contusions  of  the  vulva,  coming  on  during  the  puerperal 
state  or  apart  from  it,  are  interesting  from  the  therapeutic  point 
of  view  if  they  lead  to  the  production  of  a  hematoma. 

These  vulvar  hematomas,  often  described  as  thrombi  of  the 

1  In  particular  is  this  the  case  during  pregnancy.  Nachmacher  has  published  the 
history  of  a  woman  in  whom  rupture  of  a  vulvar  varix  in  the  last  month  of  pregnancy 
lead  to  her  death  from  hemorrhage  in  an  hour  (Berlin,  klin.  Woch.,  1890,  p.  968).  Hyde 
has  even  seen  death  come  on  in  40  minutes  as  the  result  of  the  rupture  of  a  varix  due  to 
a  fall  (Transactions  of  the  Obstetrical  Society,  London,  T.  XL). 


102  SURGERY   OF   THE    VULVA 

vagina,  result  from  tearing  of  the  bulb  of  the  vulva,  and  the 
blood  collects  in  the  labia  majora.1 

If  the  hematoma  is  small,  one  confines  oneself  to  securing 
asepsis  of  the  integuments,  which  is  important  when  these  are 
excoriated,  otherwise  the  infection  of  the  hemorrhagic  collection 
subjacent  may  occur  by  microbic  invasion. 

If  the  hematoma  is  large,  incise  it  freely,  evacuate  the  clots, 
stop  the  bleeding  and  finally  suture  it,  being  careful  that  the 
sutures  completely  encircle  the  hematoma  cavity,  in  order  to  do 
away  with  the  cavity  which  may  again  fill  up  after  fresh  bleeding. 

If  the  walls  of  the  cavity  are  too  contused  and  result  of  the 
union  is  doubtful,  tampon  it  with  iodoform  gauze. 

When  the  hematoma  is  infected,  whatever  its  size,  make  an 
early  and  free  incision. 

In  all  cases  the  incision  is  made  on  the  most  prominent  part 
of  the  tumor  and  parallel  to  the  axis  of  the  labia  majora. 

3.  Treatment  of  Inflammatory  Lesions. 
Inflammatory  lesions  may  be  superficial  or  deep. 

1.  Superficial  Inflammatory  Lesions. 

Certain  of  these,  such  as  inflamed  sebaceous  cysts  and  furuncles, 
are  in  no  way  peculiar  and  should  be  treated  on  the  same  lines 
as  in  other  regions. 

Erythema  is  not  uncommon  among  diabetic,  stout,  and  also 
certain  patients  whose  skin  is  easily  irritated  by  a  leucorrheal 
discharge.  Alkaline  vaginal  injections  and  local  application  of 
inert  powders  is  generally  sufficient. 

Intertrigo,  so  often  seen  in  the  neighborhood  of  the  vulva  in 
fleshy  women,  is  best  treated  by  local  bathing  of  the  parts,  using 
a  solution  of  sublimate  1  to  20,000,  and  by  the  application  of 
such  powders  as  oxide  of  zinc,  talc,  etc. 

Herpes  demands  no  special  treatment.  Local  bathings  of  the 
parts  with  calamine  lotion  and  applications  of  powder  and  talc. 
If  ulceration  persist,  application  of  nitrate  of  silver,  1  in  30,  is 
very  useful. 

1  The  bulb  is  situated  above  the  median  aponeurosis.     It  is  an  organ  of  the  vulva,  not 
of  the  vagina  (see  Fig.  85) . 


TREATMENT  OF  INFLAMMATORY   LESIONS  103 

Eczema  is  treated  by  the  ordinary  means,  not  forgetting  that 
its  origin  may  be  due  to  a  vaginal  discharge  and  the  patient  may 
be  diabetic. 

Erythrasma,  which  generally  attacks  the  genito-crural  fold, 
is  first  treated  with  tincture  of  iodine,  and  when  desquamation  is 
produced,  apply  talc  powder  to  which  a  little  salicylic  acid  has 
been  added,  2  to  100. 

Vulvitis  requires  a  special  treatment  varying  according  to 
the  case: 

In  sebaceous  vulvitis  characterized  by  a  hypersecretion  of 
sebaceous  material,  which  forms  a  sort  of  membranous  lamina 
on  the  internal  face  of  the  labia  majora,  the  labia  minora  and 
around  the  clitoris,  and  leaving  exposed  below  this  lamina, 
when  rubbed  off,  a  mucous  membrane  redder  than  normal. 
For  such  a  condition  we  prescribe  local  bathing  of  the  parts, 
minute  attention  to  cleanliness  and  soapy  or  alkaline  lotions. 

In  mucous  vulvitis,  where  there  is  a  hypersecretion  of  mucus 
and  where  the  patient  complains  of  wetting  herself,  order  cold 
lotions  and  astringents  (calamine  lotion,  solution  of  alum,  and 
sulphate  of  zinc)  and  the  application  of  inert  powders. 

Vulvitis  complicated  with  vaginitis  is  treated  as  vaginitis. 

We  now  pass  to  the  vulvo-vaginitis  of  infancy.  It  is  now 
recognized  to  be  due,  in  little  girls,  to  gonococcal  inoculation. 

Its  treatment  should  first  of  all  be  prophylactic.  We  should 
treat  the  discharges  from  which  the  mother  suffers,  and  to  avoid 
risks  of  contagion  by  towels  and  sponges,  also  in  hospitals  the 
same  thermometer  should  not  be  used  for  taking  the  tempera- 
ture in  the  vagina  of  a  number  of  children.  Epidemics  of 
vulvitis  have  been  traced  to  this  cause. 

Curative  treatment  consists  in  vulvo-vaginal  lavage  which 
should  be  made  by  the  doctor  himself  with  a  little  cannula,  a 
red  rubber  catheter,  and  a  solution  of  permanganate  of  potash, 
1  to  1000.  The  mother  should  be  advised  to  wash  the  external 
parts  well  with  a  solution  of  sublimate  1  to  10,000  and  in  the 
intervals  between  the  lavages  to  separate  the  labia  by  placing 
between  them  a  tampon  of  antiseptic  wrool  (boric  acid  or  salol, 
etc.) . 

Combined  with  the  local  there  should  also  be  a  general  treat- 
ment (iodide  of  iron  and  sulphur  baths) . 


104  SURGERY   OF   THE    VULVA 

Certain  of  these  vulvo-vaginites  are  accompanied  by  the 
development  of  fungoid  growths  around  the  urethral  orifice, 
which  may  give  rise  to  hemorrhage  and  may  simulate  a  criminal 
attack  or  give  rise  to  a  belief  in  the  premature  appearance  of 
menstruation.  A  few  applications  of  silver  nitrate  (1  to  100) 
suffice  to  cause  their  disappearance.- 

2.  Treatment  of  Deep  Inflammatory  Lesions. 

The  lymphangitis  abscess  of  the  labia  majora  should  be 
treated  by  direct  incision  as  elsewhere,  as  also  abscesses  developed 
around  a  foreign  body  or  a  suppurating  hematoma,  etc. 

The  only  deep  inflammatory  lesion  of  the  vulva  which  need 
detain  us  is  inflammation  of  the  vulvo-vaginal  gland  of  Bartholin 
or  Bartholinitis. 

If  a  purulent  collection  exist,  it  may  be  limited  to  the  gland 
itself,  or  extend  throughout  the  labium.  In  any  case  the 
treatment  is  the  same.  A  more  or  less  extended  incision  parallel 
to  the  main  axis  of  the  labium  and  on  its  internal  surface.  As 
the  incision  tends  to  close  spontaneously,  before  the  abscess  has 
disappeared,  tamponing  of  the  cavity  may  be  required  after  the 
excision  of  an  ellipse  in  order  to  prevent  too  rapid  cicatrization. 

In  spite  of  all  precautions,  it  is  not  infrequent  to  see  fistulas 
persist,  and  an  abscess  reappear  from  still  affected  portions  of  the 
gland.  Thus,  in  order  to  obtain  a  cure,  we  practice  the  complete 
excision  of  the  gland. 

This  excision  should  not  take  place  during  the  acute  stage; 
it  is  better  to  \vait  eight  or  ten  days  after  the  incision  of  the 
abscess.  Immediate  extirpation  should  only  be  advised  in 
chronic  cases  or  in  Bartholinitis  at  the  outset  of  the  attack  when 
only  a  simple  indurated  nucleus  with  a  softened  center  exists;  in 
a  word,  if  the  inflammation  is  primarily  or  secondarily  limited 
to  the  gland. 

Extirpation  should  be  carried  out  in  the  same  lines,  as 
we  will  mention  further  on,  for  the  excision  of  vulvo-vaginal 
cysts. 

It  is  indicated  during  a  pregnancy,  because  the  suppurating 
seat  of  these  chronic  inflammations  of  Bartholin's  gland  may  be 
the  cause  of  infection  during  parturition  and  the  dangers  of 


TREATMENT  OF  INFLAMMATORY  LESIONS  105 

abortion  as  a  sequel  to  the  operation  are  not  as  great  as  was 
formerly  thought. 

If  Bartholinitis,  has  not  been  methodically  treated,  a  fistula 
may  result.  For  simple  fistulas,  excision  of  the  tract  and 
glands  suffie.es.  For  fistulas  opening  on  the  internal  surface 
of  the  vulva  and  the  perineum,  more  particularly  those  which 
tend  to  burst  into  the  anal  canal  the  little  operation  we  have 
just  described  is  insufficient.  It  will  be  found  necessary  to 
completely  divide  the  perineum  down  to  the  level  of  the  fistulous 
tract  which  is  then  excised  and  then  proceed  to  the  reconstruction 
of  the  perineal  body  by  one  of  the  procedures  which  we  will 
describe  Jater  on.1  Spontaneous  cicatrization  always  leaves 
an  insufficient  perineum. 

3.  Treatment  of  Kraurosis  and  Leucoplasia. 

Leucoplasia,  characterized  by  the  development  of  white 
plaques,  requires  a  very  simple  treatment.  Avoid  all  causes  of 
irritation  and  use  alkaline  injections.  Only  plaques  wrhich  are 
thickened  demand  excision,  because  one  should  always  fear  in 
such  conditions  the  secondary  development  of  cancer. 

Kraurosis  ( K/oavpwo-is,  retraction)  is  characterized  by  the 
atrophic  retraction  of  the  skin  and  treated,  in  the  majority  of 
cases,  by  a  purely  medical  routine  (minute  cleanliness,  treatment 
of  associated  vaginal  discharges,  injections  and  washing  with 
emollients  and  alkalines,  etc.).  Surgical  treatment  is  only 
required  in  cases  complicated  with  persistent  leucoplasia  and 
dispareunia.2 

4.  Treatment  of  Vulvar  Pruritus. 

As  in  all  cases  of  pruritus,  we  must  look  for  and  treat  the  cause. 
This  is  at  times  quite  evident:  pediculi,  intestinal  wrorms,  dirt, 
or  vaginal  discharges.  These  last  named  may  be  very  copious. 
To  demonstrate  the  role  they  play  place  a  tampon  in  the  vagina 
and  the  itching  disappears  so  long  as  the  tampon  remains  in 
place. 

1  See  Perineorrhaphy. 

2  Jayle,  Vulvar  Kraurosis.    Review  of  Gynecology  and  Abdominal  Surgery,  Paris,  1906, 
p.  633. 


106  SURGERY   OF   THE    VULVA 

Diabetes  may  be  the  cause,  by  its  hematogenous  action  or 
local  irritation  of  the  urine. 

Pruritus,  essentially,  can  only  be  admitted  after  a  vigorous 
search  shows  no  other  cause. 

Injections  with  very  hot  boiled  water,  or  vaginal  ovules 
containing  a  little  chlorhydrate  of  cocaine  (0.02  to  0.03  centi- 
grams— 1/3  to  1/2  grain),  or  applications  of  silver  nitrate  1  to  20, 
etc.,  produce  a  great  relief. 

As  to  real  treatment  of  pruritus,  it  has  differed  according  to 
the  idea  entertained  of  the  affection.  Sanger  and  Kelly,  who 
believe  it  to  be  a  dermato-neuritis,  advise  the  excision  of  the 
plaques  at  the  seat  of  the  pruritus.  Ruge,  who  thinks  it  is  a 
parasitic  condition,  advocates  a  simpler  treatment.  He  washes 
and  cleans  well  with  soap  the  cervix,  vagina  and  vulva  after 
which  he  applies  to  the  last  carbolized  vaseline  (3  to  4  per  100). 
He  recommences  his  cleaning  operation  after  a  few  days  and 
soon  obtains  a  complete  cure.  Hirst  and  Tavel  advise  a 
resection  of  the  nerves  involved  in  inveterate  cases. 

4.  Operations  on  the  Vulva. 

Some  of  the  operations  on  the  vulva  are  of  slight  importance 
and  won't  detain  us. 

Adhesions  of  the  prepuce  of  the  clitoris  are  perhaps  accom- 
panied by  retention  of  smegma  and  veritable  concretions  result- 
ing in  consequent  irritation  and  masturbation.  These  may  be 
separated  back  by  a  little  blunt  sound  after  the  prepuce  has 
been  drawn  back  toward  the  pubis  and  a  little  cocaine  applied 
locally.  After  freezing  is  complete,  the  clitoris,  red  and  denuded, 
is  smeared  over  with  vaseline  and  the  mother  is  advised  to  draw 
back  the  prepuce  of  the  clitoris  daily,  vaselining  the  parts  so  as  to 
prevent  the  further  formation  of  adhesions.1 

Excision  of  the  labia  minora  is  practised  by  certain  people, 
such  as  the  Maures,  following  a  ritual  similar  to  that  of  the 
Israelites'  circumcision.  Its  practice  for  hypertrophy  is  rarely 
called  for. 

Speaking  generally,  the  operations  done  on  the  vulva  are 
divided  into  three  groups : 

1  Bacon,  Adhesion  of  the  Female  Prepuce.     Americ.  Gyn.  and  Obstet.  Journal,  N.  Y., 
1898,  T.  VI,  p.  278.     Kelly,  p.  6,  Gyn.,  N.  Y.,  1898. 


OPERATIONS  ON  THE   VULVA  107 

1.  Operations  to  constrict  or  close  the  vulvar  orifice. 

2.  Operations  to  increase  the  orifice. 

3.  Operations  of  excision. 

1>  Operations  Constricting  or  Closing  the  Vulva. 

Operations  for  the  constriction  of  the  vulvar  orifice  are  three : 
Infibulation,  episiorrhaphy,  and  nymphorrhaphy.  Strictly  speak- 
ing, these  three  operations  belong  to  the  domain  of  retrospective 
surgery. 

This  is  above  all  true  of  infibulation  which  consists  in  uniting 
the  labia  majora  by  a  metallic  ring.  Frequently  practised  in  the 
middle  ages,  it  still  exists  in  Ethiopia,  where  it  appears  to  be  the 
rule  to  unite  with  an  amianthus  wire  the  labia  majora  in  little 
girls  of  one  year  to  one  and  one-half  years.  At  the  time  of 
marriage  the  mother  of  the  prospective  husband  examines  the 
future  bride  and  her  consent  is  not  gained  until  the  ring  is  found 
to  be  quite  intact.  It  is  afterward  incised  with  considerable 
pomp. 

In  episiorrhaphy1  the  labia  minora  are  removed  and  the 
internal  surfaces  of  the  labia  majora  are  rawed  and  allowed  to 
unite.  Nymphorrhaphy2  is  an  operation  of  the  same  kind,  in 
which  the  freshening  and  suturing  occur  in  the  labia  minora. 
Employed  in  cases  of  rebellious  vesico-vaginal  fistulae,  these 
two  operations  constitute  a  deplorable  necessity,  not  being  able 
to  do  better,  and  are  only  very  exceptionally  indicated.  The 
vagina  is  transformed  into  a  diverticulum  of  the  bladder  and 
becomes  most  frequently  the  seat  of  calculi  formation  necessi- 
tating a  secondary  opening  of  that  which  has  been  closed. 

2.  Operations  Enlarging  the  Vulvar  Orifice. 

Treatment  of  Adhesion  of  the  Labia. — The  simplest  of  these 
operations  is  that  in  which  the  labia  are  separated  by  a  grooved 
sound.  The  condition  of  the  adhesion  of  the  labia  is  brought 
about  by  a  congenital  lesion,  or  following  on  an  inflammation 
which  has  caused  a  disappearance  of  the  surface  epithelium 

1  Of  tiri.fffi.ov,  lip. 

2  Of  nymphs,  labia  minora. 


108 


SURGERY   OF   THE    VULVA 


and  consequently  union  of  the  lower  portion  of  the  labia  majora 
and  upper  portion  of  the  labia  minora.1 

Treatment  of  Cicatricial  Constrictions. — The  cicatricial  con- 
strictions may  be  treated  by  simple  dilatation,  but  this  only 
gives  temporary  results.  The  same  may  be  said  of  simple 
section  of  the  cicatricial  frenum.  Complete  cure  can  only  be 
obtained  by  an  operation  of  excision  of  the  cicatricial  tissue  and 
making  good  the  loss  of  substance  by  an  immediate  autoplastic 
operation. 

Division   of    the   Vulvo-vaginal   Tissues.  -Introduced    into 


FIG.     86. — Division  of  the  vulvo- vaginal  tissues.     On  the  left  side  simple  division ; 
on  the  right,  division  with  lateral  perineotomy. 

Germany  by  Duhrssen  and  into  France  by  Chaput,  it  consists  of 
a  long  posterolateral  incision.  The  incision  may  be  made  from 
without  in  or  by  transfixion.  Commencing  at  the  skin,  it  is 
represented  by  a  line  which  commences  about  2  cm.  (1/5  inch) 
above  the  fourchette,  is  directed  down  and  out  toward  the 
ischium,  and  is  about  1  1/2  to  2  inches  or  4  to  5  cm.  long. 
Deeply,  it  is  continued  above  into  the  vagina,  about  5  cm.  (2 

1  Sanger,  Conglutinatio  labiorum.     Cent.-Bl.  f.  Gyn.,  Leipzig,  1891,  No.  50.     Ross 
(J.  W.),  Conglutinatio  labiorum.     Cent.-Bl.  f.  Gyn.,  1892,  p.  284. 


OPERATIONS  ON  THE   VULVA  109 

inches)  from  the  border  of  the  vulva,  and  in  the  same  plane  as 
the  cutaneous  incision. 

A  few  forceps  having  been  applied  and  hemostasis  secured, 
sufficient  access  is  afforded  the  surgeon  to  carry  out  the  operation, 
which  is  finished  by  suturing. 

If  he  wishes  to  reestablish  the  parts  as  before,  he  commences 
by  uniting  the  perineal  and  vaginal  segments  with  a  stout 
thread  of  silk  or  silver  in  the  line  of  the  small  axis  of  the  diamond- 
shaped  space  created  by  the  incision.  This  suture  passes  below 
the  bleeding  surfaces,  so  as  to  obliterate  any  virtual  cavity.  He 
then  sutures  with  catgut  the  vaginal  mucous  membrane  and 
the  external  parts  with  silkworm  gut. 

In  cases  where  a  vulvo-vaginal  stricture  exists,  as  has  been 
observed  in  certain  vesico- vaginal  fistulas,  it  has  been  found 
better,  after  tying  the  vessels,  to  allow  the  wound  to  cicatrize  with- 
out intervention,  or  else  suture  it  in  the  following  way :  It  may  be 
sutured  perpendicularly  to  the  direction  of  the  wound,  and  we 
commence  by  placing  the  first  stitch  in  the  long  axis  of  the 
lozenge-shaped  space  and  suture  the  vaginal  mucous  membrane 
to  the  skin  and  then  suturing  to  the  right  and  to  the  left  the  rest 
of  the  wound,  until  the  skin  and  mucous  membrane  of  the 
vagina  are  united.  In  this  manner  we  obtain,  as  our  experience 
has  taught  us  on  many  occasions,  the  healing  of  the  vulvo- 
vaginal  stricture,  having  first  made  use  of  the  incision  as  a  pre- 
liminary portal  of  entry. 

Side  by  side  with  the  vulvo-vaginal  incision  we  should  mention 
the  procedure  employed  by  Michaux,  which  is  a  lateral  perine- 
otomy  combined  with  a  vulvo-vaginal  incision.  Michaux  makes 
an  ischio-rectal  incision  about  10  cm.  (4  inches)  long,  parallel  to 
the  internatal  cleft  and  a  good  finger's  breadth  above  it.  The 
incision  commences  posteriorly  about  the  level  of  the  anus  and 
terminates  where  a  line  between  the  ischium  and  pubis  crosses 
the  labia  majora  anteriorly.  It  is  deepened  until  it  just  comes 
into  contact  with  the  external  surface  of  the  vagina  which  is 
incised.  We  may  continue,  if  necessary,  the  incision  as  far  as 
the  vulva  and  in  this  manner  succeed  in  making  a  vulvo-vaginal 
cleft. 

The  indications  for  division  of  the  vulvo-vaginal  tissues 
appear  to  us  to  be  very  restricted.  As  a  preliminary  to  vaginal 


110  SURGERY   OF   THE    VULVA 

hysterectomy  it  should  be  completely  rejected.  If  the  size  of  the 
tumor  or  smallness  of  the  vagina  render  impossible  the  removal 
of  the  uterus  by  the  vaginal  route,  it  is  much  simpler  to  have  re- 
course to  abdominal  hysterectomy  or  to  remove  it  in  fragments. 
Vulvo-vaginal  splitting,  however,  has  its  use  in  certain  cases  of 
perineal  dystocia  and  in  certain  uterine  operations  in  virgins,  for 
the  removal  of  certain  vaginal  tumors  and  finally  for  the  treat- 
ment of  certain  vesico-vaginal  fistulas  which  are  difficult  of  ac- 
cess, particularly  those  that  extend  high  and  are  complicated  by 
cicatrieial  contraction  of  the  vagina. 

3.  Operations  for  Excision. 

We  will  successively  study  the  excision  operations  for  inflam- 
matory lesions  and  neoplasms.  As  a  preliminary  we  will  say  a 
word  or  two  about  the  removal  of  the  clitoris,  whether  this  be 
normal  or  simply  deformed,  because  the  indications  for  its 
removal  are  quite  special. 

Removal  of  the  Clitoris. — This  has  been  recommended  in 
cases  of  hystero-epilepsy  (Baker-Brown).  It  has  given  no 
result  as  has  also  been  the  case  in  treatment  of  masturbation. 
Is  one  authorized  to  interfere  with  the  clitoris  of  a  child  which 
is  abnormally  developed  ?  It  can  happen  that  an  exaggeration 
in  the  size  of  the  organ  exposes  it  to  friction  of  clothes,  etc.,  which 
may  lead  to  masturbation.  In  short,  the  only  indication  for  the 
removal  of  the  clitoris  is  hypertrophy  when  it  is  enlarged  to 
such  a  degree  that  it  simulates  a  penis  (a  variety  of  pseudo-her- 
maphrodism  known  under  the  name  of  gynandry) .  Independent 
of  its  inconvenience  the  hypertrophy  may  be  a  cause  of  annoy- 
ance in  the  accomplishment  of  the  sexual  functions. 

Another  indication  for  the  amputation  of  the  clitoris  is 
carcinomatous  degeneration  of  the  organ. 

The  operative  procedure  for  the  amputation  of  the  clitoris 
is  very  simple.  Dissect  up  from  the  base  of  the  clitoris  a  little 
collar  of  mucous  membrane  and  then  cut  transversely  across  the 
erectile  cylinder  of  the  organ.  This  section  causes  a  slight 
venous  hemorrhage  which  two  or  three  catgut  sutures  placed 
around  the  fibrous  envelope  of  cavernous  tissue  will  suffice  to 
stop.  The  mucous  membrane  is  afterward  brought  over  the- 
little  stump  and  sutured  with  silkworm  gut. 


OPERATIONS  ON  THE    VULVA 


111 


Excision  for  Inflammatory  Lesions. — Certain  inflammatory 
disorders  may  require  excision. 

A  chancre  of  the  vulva  may  lead  to  a  sclerosing  nucleus  which 
may  persist  indefinitely  and  become  very  annoying.  In  such  a 


FIG.  87. — Hypertrophy  of  clitoris  necessitating  its  amputation. 

case  excise  the  sclerous  area,  and  an  immediate  union  will  almost 
certainly  follow. 

Lupus,  of  which  the  rodent  ulcer  in  Germany  constitutes 
only  a  variety,  should  be  treated  by  entire  removal  followed  by 
autoplasty.1  Severe  forms  of  kraurosis2  should  be  treated  in 

1  See  further  the  removal  of  malignant  tumors.     When  total  extirpation  is  impossible 
the  local  condition  can  be  improved  by  touching  up  with  a  red  cautery  or  applications  of 
lactic  acid,  concentrated  solutions  of  chloride  of  zinc,  etc. 

2  Of  five  cases  operated  by  Martin,  four  obtained  a  definite  complete  cure,  and  only  in 
one  case  did  he  get  a  recurrence.     An  extensive  extirpation  will  operate  against  this 
complication.     See  kraurosis:  Arnoux,  Contribution  &  l'6tude  du  kraurosis  vulvse.     Th. 
de  Paris,  1898-1899,  No.  621.     Jayle,  Revue  de  Gynecologic,  Paris,  1906,  p.  633. 


112  SURGERY   OF   THE    VULVA 

the  same  way,  and  leucoplasia  with  thickening  of  the  tissues.1 
Elephantiasis  of  the  vulva  is  also  a  case  for  extirpation.  In 
such  cases  it  is  at  times  very  extensive  and  yet  it  is  exceptional 
to  have  trouble  in  a  reunion  of  the  tissues.  However,  hemostasis 
will  demand  close  attention,  as  hematomas  may  so  easily  form 
and  yield  to  suppuration  as  the  preliminary  cleansing  of  the 
elephantiasis  masses  is  so  difficult.2 

Extirpation  of  Vulvar  Neoplasms. — From  the  operative  point 
of  view  these  tumors  can  be  divided  into  two  main  groups: 
Benign  tumors  and  malignant  tumors. 

I.  Treatment  of  Benign  Tumors. 

These  are  cutaneous  and  subcutaneous. 

1.  Cutaneous  Tumors.  Vegetations. — Vegetations  occur  most 
frequently  of  cutaneous  tumors.  Commence  their  treatment  by 
the  attention  to  their  causative  agent,  the  discharge,  and  using  an 
astringent  powder  such  as  alum.  These  means  are  generally 
insufficient  and  so  one  is  most  often  obliged  to  have  recourse  to 
surgical  intervention. 

Excision  with  scissors  is  only  necessary  for  extensive  vege- 
tations which  possess  a  thick  and  resistant  pedicle.  For  others 
the  sharp  curette  suffices. 

It  is  necessary  to  stretch  the  skin  well  during  the  little  opera- 
tion, so  that  the  vegetations  only  are  removed  without  undue 
scraping  of  the  surface  of  the  skin  on  which  they  are  implanted. 

Having  finished  the  curettage,  lightly  touch  up  the  bleeding 
points  with  the  thermocautery  at  a  dull  red  heat.  This  super- 
ficial cauterization  prevents  bleeding  and  prevents  a  return  of  the 
vegetations. 

A  little  iodoform  powder  and  the  application  of  a  wisp 
of  wool  suffice  to  cure  the  condition  which  leaves,  in  healing, 
no  cicatrix. 

This    extirpation  is  so  simple  that  we  advise  its  execution 

1  Pniffe  de  Magoudeau,  Contribution  a  l'e"tude  de  la  leucoke"ratose  vulvo-vaginale. 
Th.  de  Paris,  1896-1897,  No.  632.     Bex,  Leucoplasies  et  cancroi'des  de  la  muqueuse  vul- 
vo-vaginale.    Th.  de  Paris,  1887-1888. 

2  One  must  not  confound  true  elephantiasis  of  the  vulva  with  pseudo-elephantiasis, 
which  is  a  sort  of  indurated  edema  accompanying  certain  ulcerous  lesions,   more  par- 
ticularly syphilitic  lesions,  and  which,  disappearing  with  the  causal  agent,  are  never 
justifiable  of  operative  procedure. 


OPERATIONS  ON  THE   VULVA  113 

even  during  the  course  of  pregnancy  when  such  vegetations  may 
during  labor  be  a  source  of  complications.1 

Molluscum. — The  name  of  molluscum  of  the  vulva  should  be 
limited  to  the  cutaneous  fibromata  of  that  region.  These  tumors 
are  most  ofteji  pediculated.  The  simple  section  of  their  pedicle 
with  or  without  preliminary  ligature  may  lead  to  a  cure.  It  is 
better  perhaps  to  extirpate  their  base  of  implantation  and  to 
unite  with  two  sutures.  In  such  a  case  as  Jalaguier  had,  the 
molluscum  was  continuous  with  a  subcutaneous  fibrous  forma- 
tion which  extended  to  the  neighborhood  of  the  ischium  and 
caused  a  veritable  dissection. 

2.  Subcutaneous  Tumors. — These  tumors  are  fluid  or  solid. 
They  may  be  limited  to  the  vulva  or  extend  to  the  neighboring 
region. 

The  tumors  which  extend  to  neighboring  regions  are  saccular 
cysts  and  cysts  of  the  peritoneal  diverticulum  or  canal  of  Nuck. 2  The 
extirpation  of  this  category  of  tumors  is  comparable  to  that  of  a 
hernial  sac.  It  may  be  necessary,  after  incision  of  the  tissues  which 
cover  them,  to  open  the  cystic  cavity,  empty  it  of  its  contents  and 
extirpate  its  wall  and,  taking  care  to  remain  in  contact  with  its 
internal  wall  in  order  to  avoid  losing  oneself  in  the  more  remote 
planes  of  cleavage,  not  to  injure  the  vessels  or  neighboring  parts. 

Among  the  cystic  tumors  limited  to  the  vulva,  the  extirpation 
presents  nothing  of  importance.  They  are  simple  cysts  and 
sebaceous  cysts.  Others,  such  as  cysts  of  Bartholin's  glands, 
merit  more  attention. 

In  order  to  expose  them,  we  make  an  incision  along  the  most 
prominent  part  of  the  tumor,  following  the  axis  of  the  vulva 
to  the  limit  of  the  great  and  small  labia.  The  -cyst  being  thus 
exposed  is  dissected  out,  being  careful  not  to  perforate  it,  and 
remaining  directly  in  contact  with  it  so  as  to  avoid  perforating 
internally  the  lining  of  mucous  membrane  which  is  sometimes 
very  thin  and  doubles  the  wall  of  the  cyst;  externally  beware  of 
injuring  the  bulb  of  the  vulva  and  transverse  perineal  artery. 
Finish  the  operation  by  tying  all  the  vessels  in  order  to  avoid  the 
formation  of  a  hematoma  by  inserting  some  buried  catgut  sutures 
and  in  suturing  the  integuments. 

1  Lefer  (A.),  Contribution-  £  I'e'tude  des    ve'ge'tations  chez  les   femmes  enceintes. 
Th.  de  Paris,  1898-1899,  No.  492. 

a  Wechselmann,  Archiv  f.  klin.  Chir.,  Berlin,  1890,  T.  XLIII,  p.  578. 


114 


SURGERY   OF   THE    VULVA 


In  cases  where  the  cyst  presents  some  difficulty  of  extirpation, 
open  it,  curette  its  internal  surface,  and  paint  it  with  a  solution  of 
nitrate  of  silver  1  to  5,  chloride  of  zinc  1  to  10,  and  tampon  with 
a  swab  of  iodoform  gauze,  which  is  left  in  place  until  saturated 
with  pus,  renewing  the  tamponing  each  day  in  such  a  way  as  to 
keep  the  wound  open  until  filled  up  with  granulations. 

The  solid  benign  tumors  limited  to  the  vulva  (lipomata)  or 


FIG.  88. — Incision  to  expose  the  gland  of  Bartholin. 

extending  to  neighboring  parts  (fibre-adenomata  of  the  round 
ligament,  perineal  myxo-fibromata)  present  no  particular  diffi- 
culty in  their  removal.1 


II.  Treatment  of  Malignant  Tumors. 

Epitheliomas  of  the  vulva2  should  be  removed  with  the  knee 
"en  bloc"  together  with  the  ganglionic  accompaniments.     The 

1  Mauclaire,  Molluscum  pendulum  de  la  vulve.     Annales  de  gynecologic,  Paris,  1893,  T. 
II,  p.  409. 

2  Teller  (Richard),  Ueber  das  Vulvakarzionom.     Zeitsch.  f.  Geb.  u.  Gyn.,  Stuttgart, 
1907,  T.  LXI,  p.  309. 


TREATMENT  OF   VAGINISMUS 


115 


loss  of  substance  is  rectified  by  autoplastic  procedures.  The 
only  point  of  importance  is  to  see  carefully  to  the  repair  of  the 
urethral  orifice  when  the  tumor  occupies  the  region  of  the  meatus 
in  such  a  manner  that  the  patient  will  not  be  exposed  to  compli- 
cations allied  to  secondary  stricture  of  the  new  urethra  (see 
Figs.  89,  90  and  91). 

When  the  epithelioma  is  inoperable,  a  palliative  treatment  is 
sufficient,  protecting  the  thighs  with  an  ointment  (vaseline  and 
oxide  of  zinc  25%).  The  local  irritation  is  produced  by  the 
contact  of  an  irritating  discharge  coming  from  the  ulceration. 
The  ulcerated  surface  should  be  washed  with  antiseptic  solutions 


;.  89.  FIG.  90.  FIG.  91. 

Resection  of  the  meatus  and  autoplasty  after  extirpation  of  the  anterior  part  of  the 

vulva  (after  Kelly). 

afterward  powdered  with  ipdoform  or  even,  in  case  of  bleeding, 
in  the  event  of  it  being  covered  with  sphacelated  granulations,  to 
curette  it.  Some  surgeons,  following  Kraske,  advise  the  applica- 
tion of  a  cutaneous  flap  to  the  ulcerated  surface  after  scraping.1 

Very  exceptionally  one  may  be  called  upon  to  remove  a  cancer 
of  Bartholin's  gland.2 

5.  Treatment  of  Vaginismus. 

Vaginismus  is  characterized  by  a  painful  reflex  contraction  of 
the  sphincter  of  the  vulvo-vaginal  orifice.     It  involves  the  sphinc- 

1  Kraske,  Munchener  med.  Woch.,  1889,  p.  1. 

2  Giuseppe  Trotta,  Un  caso  di  carcinoma  della  glandola  del  Bartolini.     Archivio  di 
Ostetricia  et  Ginecologia,  Napoli,  1900,  T.  VII,  No.  4. 


116  SURGERY  OF   THE    VULVA 

ter  of  the  vulva  (constrictor  of  the  vulva)  and  the  sphincter  of  the 
vagina  (anterior  fibers  of  the  levator  ani)  which  leads  to  a  dis- 
tinction between  an  inferior  and  superior  vaginismus. 

The  strongest  treatments  have  been  suggested  for  this  affec- 
tion which  affection,  although  of  no  gravity,  is  nevertheless  very 
painful. 

In  order  to  procure  fertilization  of  the  ovum,  Gaillard 
Thomas  advises  the  performance  of  coitus  under  anesthesia, 
which  procures  a  relaxation  of  the  sphincter.  Others  have 
suggested  section  of  the  nerves  to  the  vulva.  To-day  these 
methods  are  completely  abandoned. 

The  first  duty  of  the  gynecologist  is  to  discover  the  cause  of  the 
condition.  If  there  be  a  ureteral  caruncle,  vaginitis,  a  fissure, 
painful  excoriations,  or  a  localized  increased  sensitiveness  follow- 
ing on  the  first  coitus,  we  must  absolutely  forbid  all  sexual  com- 
munication and  treat  the  lesion  which  may  cause  the  reflex  con- 
striction. As  it  most  frequently  occurs  in  nervous  women,  one 
might  with  advantage  prescribe  tepid  irrigations  and  anti- 
spasmodics  internally.  The  first  coitus  should  only  be  allowed 
when  all  local  hypersensitiveness  has  disappeared  and  after  the 
application  of  cocainized  vaseline. 

Lomer  has  obtained  cures  by  the  application  of  continuous 
currents. l 

We  have  always  been  able  to  avoid  the  operative  intervention 
which  we  will  now  describe  and  \vhich  has  been  some  time  in 
vogue. 

1.  Brusque  Dilatation  under  Anesthesia. — This  can  be  very 
simply  carried  out  with  Trelat's  speculum. 

2.  Excision  of  the  Hymen  and  of  the  Vaginal  Entrance.— 
Marion   Sims    practised  the  excision  of  the  hymen,  dilated  the 
vulvo- vaginal  orifice  with  two  fingers  and  then  made  to  the  right 
and  left  of  the  median  posterior  column  of  the  vagina  two  incisions 
which  came  together  below  and  posteriorly  on  the  median  line  of 
the    perineum,    thus    producing    a    Y-shaped    incision.     These 
incisions  partly  cut  through  the  constrictor  and  he  then  forcibly 
dilated  the  orifice.     For  some  days  following  this  operation  he 
left  a  conical  dilator  in  position  for  four  or  five  hours  daily. 

3.  Plastic    Operations. — Numerous    procedures    have    been 

1  Lomer,  Centr.-Bl.f.  Gyn.,  1889,  p.  870. 


TREATMENT  OF   VAGINISMUS 


117 


devised.  All  incise  the  skin,  expose  the  constrictor,  cut  a  por- 
tion of  the  fibers,  and  tear  across  what  remains,  and  finish  with  a 
suture  of  the  cutaneous  incision. 

Pozzi,  after  excision  of  the  hymen  and  forcible  digital  dilata- 
tions of  the  yulvar  orifice  makes  on  each  side  an  oblique  incision 
of  3  to  4  cm.  antero-posteriorly,  which  goes  much  beyond  the 
hymen.  He  notches  the  constrictor,  dissects  up  the  lips  of  the 
incision  and  unites  it  at  right  angles  to  its  original  dissection; 
thus  one  can  obtain  at  the  same  time  an  increase  in  size  of  the 
vulvar  orifice  and  an  eversion  of  the  vaginal  mucous  membrane, 
thus  submitting  to  the  friction  of  coitus  that  zone  from  which 
reflex  actions  spring.1 


FIG.  92.  FIG.  93. 

Plastic  operation  for  vaginismus. 

In  Fig.  92  on  one  side  the  incision  which  goes  some  distance  beyond  the  hymen  and 
on  the  other  side  the  open  wound.  In  Fig.  93  the  lips  of  the  incision  are  dissected  up, 
the  constrictor  notched  and  the  operation  terminated  by  suture. 

4.  Resection  of  the  Internal  Pudic  Nerve. — Tavel  advises  the 
following  procedure:  About  the  middle  of  the  space  which 
separates  the  tuberosity  of  the  ischium  from  the  anus  he  makes 
an  incision  about  8  to  10  cm.  (3  1/4  inches  to  4  inches)  long,  the 
direction  of  which  is  sagittal  and  of  which  the  extremity  corre- 
sponds to  a  line  joining  the  two  ischia. 

After  having  divided  the  skin  and  subcutaneous  fatty  tissue, 
one  proceeds  externally  and  posteriorly  toward  the  internal  face 
of  the  ischium.  In  this  manner  one  avoids  injuring  the  inferior 
hemorrhoidal  nerve,  which  comes  out  at  the  level  of  the  sciatic 

1  Veit  cuts  across  the  integuments  and  the  constrictor  of  the  vulva  by  an  incision 
radiating  from  the  vulvar  orifice.  Then  he  transforms  his  vertical  incision  into  a  trans- 
verse one  by  reuniting  the  vaginal  mucous  membrane  to  the  skin. 

Doyen  incises  the  fourchette  transversely  to  the  extent  of  30  to  40  mm.  This  inci- 
sion is  made  in  one  cut  with  a  bistoury  or  by  several  cuts  with  a  straight  scissors.  The 
anterior  lip  of  the  wound  is  then  seized  in  a  pair  of  ring-bladed  forceps  and  separated 
from  the  subjacent  tissues  to  a  depth  of  about  30  mm.  The  sphincter  being  thus 
exposed  is  incised  transversely. 


118  SURGERY   OF   THE    VULVA 

spine.  Through  the  fascia  which  covers  the  obturator  internus, 
one  can  feel  the  palpitations  of  the  internal  pudic  artery.  The 
aponeurotic  sheath  which  surrounds  it  is  split  and  one  can  then 
isolate  the  nerve  from  the  artery  and  accompanying  veins. 

It  is  also  imperative  to  distinguish  the  various  branches  accu- 
rately in  order  to  preserve  the  anal  subdivision  of  the  perineal 
branch.  In  order  to  do  this  pass  a  sound  under  these  nervous 
filaments  and  this  will  provoke  contractions  in  the  corresponding 
muscles ;  the  sensitive  branches  can  be  recognized  by  the  fact  thai 
traction  exercised  on  them  causes  a  depression  of  the  points  of 
skin  which  they  supply. 

After  having  cut  the  nerves  as  far  back  as  possible,  the  per- 
ipheral end  is  taken  in  a  pair  of  Kocher's  forceps,  and  turned 
round  and  round  on  the  forceps,  and  its  terminal  portion  is  thus 
completely  torn  out.  This  withdrawal  is  limited  to  the  branches 
which  correspond  to  the  hyperesthetic  area. 

The  edges  of  the  incision  are  reunited  without  drainage  in 
order  to  avoid  the  very  frequent  secondary  infection  which  occurs 
in  this  region. 


CHAPTER  II. 

SURGERY  OF  THE  VAGINA. 

Summary. — Treatment  of  traumatic  lesions  (wounds,  hematomas, 
foreign  bodies). — Treatment  of  inflammatory  lesions. — Treatment  of 
tumors  (benign,  malignant). — Treatment  of  strictures  and  atresia  of  the 
vagina;  formation  of  neo- vaginas. 

1.  Treatment  of  Traumatic  Lesions. 

1.  Treatment  of  Wounds. 

When  one  is  confronted  with  a  vaginal  wound,  one  must 
enquire  first  into  the  conditions  which  produced  it.  With  the 
exception  of  operative  wounds,  the  causes  ordinarily  met  with  are: 
criminal  abortion,  coitus,1  falling  astride  an  object,  and  finally 
accouchements,2  during  which  tears  of  the  vagina  occur  espe- 
cially at  the  twro  extremities,  injuring  at  the  same  time  the  cervix 
uteri  and  the  perineum.  This  is  explained  by  the  fact  that  the 
vagina  is  more  supple,  and  more  capable  of  dilatation  at  any  part 
of  its  course  than  at  the  two  extremities. 

The  treatment  of  these  wounds  consists  of  twro  separate  acts : 
to  stop  hemorrhage  and  prevent  infection.  To  fulfil  these  condi- 
tions the  best  course  is  to  suture  the  wound. 

After  evacuation  of  the  clots  and  cleansing  of  the  vagina  by 
a  copious  irrigation,  one  should  methodically  examine  the  wTound 
with  the  aid  of  specula. 

Suture  it  with  catgut  and  place  a  tampon  of  iodoform  gauze 
in  the  vagina.  Tamponing  without  suture  is  only  used  wrhen 
nothing  else  can  be  done. 

When  the  wound  is  complicated  by  the  presence  of  a  foreign 
body,  the  removal  of  the  same  is  indicated.  Generally  easy,  it 
may  be  very  painful  if  the  body  is  engaged  in  the  wound  and 

1  Neugebauer  (F.),  Venus  cruenta  violans  interdum  occidens.     M onalschr.  f.  Geb.  u. 
Gyn.,  Berlin,  T.  IX,  p.  221. 

2  Morel  (J.),  Rupture  et  perforation  de  la  paroi  posterieure  du  vagin  pendant  1'ac- 
couchement.     Th.  de  Paris,  1897-1898,  No.  35. 

119 


120  SURGERY   OF   THE    VAGINA 

buried  wholly  or  partly  in  the  vagina.     The  movements  of  its 
abstraction  should  be  very  gentle. 

If  an  infection  develops  secondarily  to  the  wound,  involving 
the  paravaginal  cellular  tissue  or  an  encysted  peritonitis,  a  large 
incision  and  drainage  are  indicated. 

2.  Treatment  of  Hematomas. 

We  have  seen  that  it  is  imperative  to  distinguish  vaginal  from 
vulvar  hematomas.1  Rarer  and  yet  coming  on  like  the  others, 
during  the  puerperium,  vaginal  hematomas  often  resolve  spon- 
taneously. It  is  only  necessary  to  maintain  the  asepsis  of  the 
vagina  in  order  to  avoid  infection  of  the  effusion  when  this  is 
moderate. 

The  progressive  increase  of  the  hematoma  by  continuation  of 
the  hemorrhage  or  its  suppuration  would  indicate,  on  the  con- 
trary, a  free  incision  with  plugging  of  the  cavity  in  the  first  instance 
and  drainage  in  the  second.  For  large  intrapelvic  hematomas, 
the  vaginal  route  is  the  best  if  the  effusion  is  already  somewhat 
old ;  on  the  contrary,  if  it  is  a  progressively  developing  hema- 
toma, we  should  have  recourse  to  the  abdominal  route.2 

3.  Treatment  of  Foreign  Bodies. 

Foreign  bodies  of  the  vagina  may  be  divided  into  avowable 
(tampons,  pessaries)  and  unavowable  (introduced  during  mastur- 
bation), thus  presenting  a  variety  which  baffles  description. 

These  foreign  bodies  produce  by  their  presence  vaginal  inflam- 
mation and  even  ulceration,  leading  sometimes  to  strictures  and 
communications  with  neighboring  cavities  (bladder  and  rectum) . 
Sometimes  even  serious  complications  arrive,  septic  troubles,  etc., 
the  typhoid  state  producing  death.  In  these  conditions  treatment, 
as  one  can  understand,  is  not  alwrays  the  simplest. 

The  first  thing  to  do  is  to  remove  the  foreign  body.  To  do  this 
carefully  clean  the  vagina,  vaseline  it  and  then  attempt  extraction 
with  the  aid  of  forceps  introduced  on  the  finger.  This  extraction 
is  unfortunately  not  always  possible  by  reason  of  the  nature  and 

1  Chaintre,  Thrombus  intra-vaginaux.     Lyon  medical,  1890,  T.  LXIII,  p.  43. 

2  J.  Whitridge  Williams,  Intrapelvic  Hematoma  following  Labor  not  Associated  with 
Lesions  of  the  Uterus.     Am.  J.  of  Obstetr.,  New  York,  1905,  T.  II,  p.  442. 


TREATMENT  OF  INFLAMMATORY  LESIONS  121 

position  of  the  foreign  body,  of  its  bulging  into  the  vaginal  wall, 
or  because  of  the  hymen  or  a  cicatricial  structure  of  the  vagina. 
One  occasionally  has  to  pick  it  out  piecemeal  with  a  cutting 
forceps  or  with  a  Gigli  saw,  having  first  fixed  the  body  wTith  a  pair 
of  strong  forceps. 

Having  removed  the  foreign  body,  disinfect  the  surrounding 
parts,  and  if  necessary  touch  up  the  ulcerations  with  a  solution  of 
silver  nitrate  (5  per  cent.).  As  a  final  act  treat  the  vaginitis  and 
repair  any  fistula  produced. 

2.  Treatment  of  Inflammatory  Lesions. 
Treatment  of  Vaginitis. 

The  first  point  in  the  treatment  of  vaginitis  is  to  inquire  into 
its  cause  (foreign  body,  uterine  catarrh,  cancer,  prolapse,  mas- 
turbation, etc.).  As  to  direct  treatment  of  the  vaginitis,  that  will 
vary  according  to  its  nature.  One  point  of  importance  is  to 
interdict  all  sexual  communication  whatever  be  the  nature  of  the 
vaginitis,  and  simple  lavage  of  boiled  water  will  suffice  in  vaginitis 
complicating  pregnancy.  For  mycotic  vaginitis,  injections  of 
sulphate  of  copper  2  per  cent,  is  the  treatment  of  choice. 

In  acid  leucorrhea,  one  should  prescribe  injections  of  bicarbo- 
nate of  soda,  an  ample  soupspoonful  to  a  liter  of  water.  In 
fetid  leucorrhea,  Labarraque's  solution  is  frequently  employed 
in  a  strength  of  1  to  3  soupspoonfuls  to  a  liter  of  water.  In 
chronic  vaginitis  it  is  useful  to  combine  feebly  antiseptic  injec- 
tions (sublimate  1  in  4000)  with  the  placing  in  position  in  the 
vagina  of  tampons  impregnated  with  a  mixture  of  glycerin  and 
tannin  or  alum,  which  is  left  in  twelve  to  twenty-four  hours  and 
renewed  twice  a  week. 

Gonorrheal  vaginitis  necessitates  a  more  serious  treatment. 
During  the  acute  period,  rest,  baths,  and  feeble  injections  of  per- 
manganate of  potash  (1  in  4000),  absolute  cleanliness  of  the 
external  genitals,  which  should  be  washed  three  or  four  times  daily 
with  a  solution  of  boric  acid,  and  oftener  if  the  discharge  is  abun- 
dant. A  little  later  injections  of  1  in  1000  corrosive  sublimate 
solution  preceded  by  a  thorough  cleansing  of  the  vagina  with 
soap  and  a  thorough  lavage  with  water.  It  is  even  better  to  place 


122  SURGERY   OF   THE    VAGINA 

a  tampon  of  glycerin  and  tannin  in  the  vagina  the  day  previous 
to  the  injection.  This  causes  a  shedding  of  the  most  superficial 
layers  of  the  epithelium.  The  sublimate  acts  better  on  a  mucous 
membrane  thus  treated.  After  washing  out  the  vagina  well  with 
sublimate,  it  is  slightly  tamponed  with  iodoform  gauze  to  prevent 
contact  of  its  walls. 

It  has  also  been  advised  to  paint  with  a  10  per  cent,  solution 
of  silver  nitrate.  After  having  cleaned  the  vagina  well,  one  paints 
its  walls  with  a  tampon  of  wool  soaked  in  this  solution.  Com- 
mence at  the  fundus  and  leave  no  spot  untouched.  Use  the  spec- 
ulum to  aid  this  procedure.  Then  remove  the  excess  of  solution 
with  a  piece  of  dry  hydrophile  wool.  Next  coat  the  vagina  with 
vaseline  and  place  two  tampons,  furnished  with  silk  threads, 
in  such  position  as  to  prevent  the  folds  of  mucous  membrane 
coming  into  contact  with  each  other.  The  tampons  are  removed 
in  forty-eight  hours. 

It  is  quite  evident  that  in  this  variety  of  vaginitis,  more  than 
in  the  others,  it  is  necessary  to  attack  the  gonococci  wherever  they 
may  be,  whether  in  the  cervix  uteri,  urethra,  or  in  the  peri- 
urethral  passages,  as  vaginal  reinoculations  may  occur  with  the 
greatest  ease. 

Latterally,  Landau  has  advocated  the  employment  of  yeast  in 
the  treatment  of  gonorrhea.  He  washes  the  vagina  with  sterilized 
water,  and  then  introduces  into  the  vagina  two  teaspoons  of  yeast 
and  one  teaspoon  of  grape-sugar.  A  few  minutes  after  he  intro- 
duces a  tampon  saturated  with  grape-sugar,  which  is  removed  by 
the  patient  in  eight  or  ten  hours.  These  applications  are  made 
each  second  day. 

In  a  general  way,  for  all  varieties  of  vaginitis  one  may  utilize 
three  methods  of  treatment  which  may  be  sometimes  of  interest 
to  combine. 

1.  Painting  with  somewhat  concentrated  solutions  of  active 
substances. 

2.  Vaginal  injections. 

3.  Application  of  tampons  of  glycerin  plus  tannin  (1  to  2) , 
alum  (5  to  100),  ichthyol   (5  or  10  to  100),  thyenol  (2  to  100)  or 
protargol  (2  to  100),  etc.     The  patients,  when  left  to  treat  them- 
selves, are  allowed    to    introduce  glycerinated  ovules,  to  which 
some  active  substance  has  been  added. 


TREATMENT  OF  TUMORS  123 

3.  Treatment  of  Tumors. 

Tumors  of  the  vagina  may  be  removed: 

1.  Directly  per  vias  naturales. 

2.  After  division  of  the  vulvo- vaginal  tissues  which  is  carried 
out    on    the    healthy    side   (Duhrssen)   or  on  the  diseased  side 
(Thorn)  or  in  the  median  line  (Thomson). 

3.  After  transverse  perineotomy  (Olshausen). 

4.  By  the  sacral  route. 

5.  By  the  abdominal  route. 

6.  By  the  combination  of  both  these  routes. 

7.  By  the  para  vaginal  route. 

None  of  these  routes  should  be  regarded  exclusive  of  the  others. 
The  nature  of  the  operation  depends  on  the  tumor  with  which 
one  is  dealing. 

1  Cysts. — Cysts  of  the  vagina,  small  and  non-infected,  are 
removed  "in  toto"  per  vias  naturales.  It  is  the  operation  of 
choice,  but  if  the  cyst  is  large,  with  prolongations  into  the  broad 
ligaments,  as  in  certain  congenital  cysts,  the  total  extirpation  of 
the  sac  is  impossible.  It  is  therefore  necessary  to  confine  one- 
self to  incision  of  the  cyst,  excising  its  prominent  position  and 
suturing  its  base  to  the  sides  of  the  vaginal  incision. 

After  having  curetted  its  epithelium,  it  is  well  rubbed  over 
with  a  piece  of  wool  held  in  a  forceps  and  soaked  with  chloride  of 
zinc  solution  1  in  10.  Afterward  the  cavity  is  tamponed  with 
iodoform  gauze  and  healing  occurs  gradually  by  healing  from 
below. 

Suppurating  cysts  are  treated  with  incision  and  drainage. 

2.  Fibro-myomata. — The  extirpation  of  these  tumors  is 
usually1  quite  easy.  The  treatment  of  choice  appears  to  be: 

A.  Incision,  then  enucleation  followed  by  two  layers  of  su- 
tures, a  superficial  and  a  deep,  in  cases  of  sessile  tumors. 

B.  Ligature  of  the  pedicle  in  polypoid  tumors. 

As  these  tumors  frequently  spring  from  the  anterior  vaginal 
wall,  torsion  should  not  be  applied  to  them,  because  that  may 
lead  to  a  tearing  of  the  bladder. 

In  such  cases,  the  volume  of  the  tumor  is  such  that,  in  order 

1  Jacob^e  (P.),  Des  Fibromes  sessiles  et  p6dicu!6s  du  vagin.     Th.  de  Paris,  1908-1909, 
No.  34. 


124  SURGERY   OF   THE    VAGINA 

to  disengage  it,  one  frequently  has  resource  to  obstetrical  forceps 
and  the  hand  introduced  into  the  rectum.  We  think  it  is  simpler 
to  take  away  the  tumor  in  fragments. 

If  the  fibromyoma  is  gangrenous  one  can,  after  extirpation 
of  the  tumor,  pack  the  site  of  enucleation  with  iodoform  gauze 
and  allow  it  to  close  gradually  up. 

3.  Malignant  Tumors. — Malignant  tumors  have  been  removed 
per  vias  naturales  or  making  a  larger  access  by  a  vulvo-vagi- 
nal  division  carried  out  on  the  healthy  side  (Duhrssen),  or 
on  the  diseased  side  (Thorn),  or  in  the  posterior  median  line 
(Thompson) . 

In  order  to  get  better  access,  Olshausen  advised  a  transverse 
perineotomy,  dividing  the  perineum  and  then  resecting  the  vagina. 
A.  Martin  is  accustomed  to  do  a  total  colpo-hysterectomy  by  the 
lower  route. 

The  immediate  results  have  generally  been  good,  but  time 
has  shown  them  to  be  disastrous.  In  almost  all  cases,  recurrence 
has  taken  place  in  a  few  months,  and  death  before  the  end  of  a 
year.1 

The  progress  realized  by  the  extirpation  of  cancer  of  the 
cervix  by  the  abdominal  route  should  fatally  lead  one  to  the 
extension  of  one's  operation  to  the  total  concomitant  extirpation 
of  the  vagina.  This  is  already  the  case.  The  uterus  and  vagina 
have  been  extirpated  by  the  abdomen  in  cases  of  cancerous  degen- 
eration of  the  latter.2  It  is  also  possible  to  operate  by  another 
route,  and  to  have  recourse,  as  already  stated,  to  the  simultaneous 
extirpation  of  the  uterus  and  the  vagina  by  the  paravaginal 
incision  of  Schuchardt.3 

We  do  not  yet  know  how  these  more  recent  operations  will 
result,  but  considering  the  frequency  of  recurrence  in4  the  rectal 

1  Kronig,  Archiv  fur  Gyn.,  Berlin,  1902,  T.  LXIII,  p.  38.     Bonnefous,  Contribution 
k  1' etude  du  cancer  primitif  du  vagin.     Th.  de  Paris,  1902-1903,  No.  88. 

2  Veit  has  operated  four  cases  in  the  following  way:  He  makes  a  circular  incision 
inferiorly  around  the  vagina,  separates  the  tissues  up  anteriorly  as  far  as  the   cervix 
uteri,  and  posteriorly  as  far  as  the  pouch  of  Douglas.     He  then  close"  the  vagina  by  a 
strong  suture  and  finishes  by  the  abdomen,  removing  uterus  and  vagina,  following  the 
usual  technic  employed  for  cancers  of  the  cervix.     He  has  operated  four  times  with 
three  cures  and  one  death.     (Handb.  der  Gyn.,  Wiesbaden,  1902,  second  edition,  T.  Ill, 
Part  I,  p.  307.) 

3  Hartmann,  Ann.  de  Gynec.,  1909,  p.  756. 

4  One  of  the  few  cases  known  of  cure  belongs  to  Lauenstein.     It  was  a  woman  operated 
on  July  12,  1888,  reoperated  in  1892  with  occurrence  on  the  cervix  uteri.     She  was  seen 
again,    cured  in  1895  (Lauenstein,  Zur  operative  Behandlung  des  primaren  Scheiden 
carcinoms.     Deutsch  Zeitschr.f.  Chir.,  1895,  T.  LXI,  p.  411. 


TREATMENT  OF  TUMORS  125 

walls,  an  occurrence  quite  inexplicable  from  the  direction  of  the 
vaginal  lymphatics,  which  tend  toward  the  hypogastric  ganglia, 
the  question  naturally  arises  if  the  new  interventions  can  give 
better  results. 

For  this  reason  many  gynecologists  have  not  hesitated  to  do 
an  excision  of  the  rectum  at  the  same  time  as  a  colpohysterectomy. 
The  operation  is  terminated  perhaps  with  an  artificial  anus  in 
the  iliac  region  (Himmelfarb),1  or  a  perineal  anus  (Pry or).2 

In  presence  of  an  inoperable  cancer,  palliative  treatment 
consists  in  cleansing  of  the  part  followed  by  a  thermo-cauteriza- 
tion  and  tamponing  with  iodoform  gauze.  Kronig  followed  this 
course  of  treatment  with  a  pregnant  woman,  arrived  at  full  term, 
and  she  had  her  accouchement  without  any  trouble.  We  believe 
it  is  better  to  do  a  Cesarean  section  in  such  a  case. 

As  palliatives,  chemical  caustics  have  been  employed,  par- 
ticularly that  of  chloride'of  zinc  (50  to  100). 

Kustner  advises  colpocleisis.  This  remedy  appears  to  us  to 
be  worse  than  the  disease,  hence  we  reject  it. 

4.  Treatment  of  Stricture  and  Atresia  of  the  Vagina. 

Previous  to  recent  times  atresia  was  always  supposed  to  be 
associated  with  an  error  of  development.  From  the  work  of 
Nagel,3  Veit4  and  Pincus,5  it  would  seem  that  atresia  is  most 
often  acquired,  and  particularly  if  the  uterus  is  well  developed, 
atresia  may  be  considered  as  the  result  of  a  pathological  process. 

This  new  conception  of  gynatresia  makes  us  think  of  the 
possibility  of  a  prophylactic  treatment. 

In  the  new-born  female  children  of  gonorrheal  mothers,  we 
may  apply  a  treatment  to  the  genital,  organs  similar  to  that  of 
Crede  for  the  eye  and  make  a  more  or  less  careful  antisepsis  of  the 
vulva.  One  should  carefully  treat  gonorrhea  of  new-born  infants 
and  minutely  examine  small  girls  affected  with  an  infectious 
acute  process  or  grave  constitutional  tendencies,  which  may 

1  Himmelfarb,   Contrib.   au  trait  ope>atoire  du  cancer  primitif  du  vagin.     Rev.  de 
Gynec.,  Paris,  1907,  p.  589. 

2  Pryor,  An  Operation  for  Primary  Vaginal  Carcinoma.     American  Gynec.  Soc., 
May,  1900,  in  Boston  Med.  and  Surg.  Journal,  October  11,  1900,  p.  373. 

3  Nagel,  Zur  Lehre  von  der  Atresie  der  weiblichen  Genitalien.     Centr.-Bl.  f.  Gyn., 
Leipzig,  1896,  p.  519. 

4  Veit,  Ueber  Hamatosalpinx  bei  Gynatresien.    Ibidem,  p.  560.    Pour  Veit,  L'hemato- 
salpinx,  qui  complique  fr£quemment  la  gynatresie,  est,  comme  cette  derniere,  sous  la 
d^pendance  d'un  meme  processus  phlegmasique  infectieux. 

8  Pincus,  Sammlung  klin.  Vortrag.,  1901. 


126  SURGERY   OF   THE    VAGINA 

accompany  vulvo-vaginitis.  We  should  also  look  for  and  treat 
complications  or  secondary  troubles,  embolism  and  thrombus  of 
the  vagina  and  vulva.  Think  of  a  gonorrheal  affection  or  a  hem- 
orrhagic  vulvo-vaginitis  when  one  is  brought  into  contact  with  one 
of  these  cases  wrongly  cited  as  precocious  menstruation.  This 
is  particularly  the  case 'if  it  occurs  in  a  new-born  child,  etc.  In 
this  manner  one  may  prevent  the  later  development  of  gynatresia. 
If  the  lesion  is  already  present,  there  are  two  aspects  of  the 
case  to  consider. 

1.  We  have  a  simple  stricture. 

2.  Or  there  is  a  complete  occlusion,  i.e.,  atresia  (aliens)  of 
the  vagina. 

1 .  Strictures  of  the  Vagina. 

In  limited  stenosis,  without  a  surrounding  quantity  of  cica- 
tricial  tissue,  simple  dilatation  suffices  often  enough  to  enable  the 
canal  to  maintain  its  accustomed  caliber.  In  such  a  condition 
we  obtained  complete  success  by  the  passage  of  bougies.  The 
case  was  that  of  a  young  girl  who  had  retention  of  her  men- 
struation due  to  union  of  the  vaginal  walls.1 

The  successive  divisions  of  vaginal  tissues,  followed  by  the 
introduction  of  balls  or  cylinders,  increasing  gradually  in  size, 
was  advocated  by  Bozeman. 

To-day,  if  we  are  dealing  with  the  cicatricial  tissue,  generally 
we  cut  through  and  follow  with  immediate  suture,  after  having 
stretched  the  structural  with  retractors.  If  we  are  dealing 
with  a  cicatrix  of  the  vaginal  vault,  draw  the  cervix  to  the  opposite 
side  and  cut  through  the  tense  tissues  and  remove  as  far  as 
possible  the  fibrous  tissue.  Secure  bleeding  vessels  and  then 
suture  the  mucous  membrane. 

If  there  exists  above  the  cicatrix  an  extensive  cicatricial  in- 
duration, one  may  injure  the  uterine  artery  during  the  excision 
of  this  tissue.  This  is  not  of  great  importance.  Of  much 
greater  importance,  however,  is  the  possible  injury  to  the  urethra 
or  the  bladder.  For  this  reason,  before  deciding  to  intervene  in 
these  cases,  weigh  well  in  the  balance  the  operative  risks  and  the 
inconveniences  resulting  from  a  cicatrix. 

'This  was  published  by  one  of  our  pupils.     Altmann,  Contribution  a  I'^tude  de  la 
retention  des  regies.     Th.  de  Paris,  1893-1894,  No.  106. 


TREATMENT  OF  TUMORS  127 

When  the  cicatricial  tissue  occupies  a  certain  length  of  the 
vagina,  incision  followed  by  suture  becomes  impossible.  It 
becomes  necessary,  after  resection  of  the  fibrous  tissue,  to  apply 
to  the  raw  surface  grafts  which  one  takes  from  parts  where  the 
vaginal  mucous  membrane  is  profuse.  It  may  be  necessary  to  do 
this  several  times  and  the  patients  generally  get  tired  of  it  before 
the  cure  is  complete. 

During  pregnancy  the  same  treatment  is  indicated. 

During  labor,  if  the  stenosis  is  slight,  we  may  cut  through  the 
strictures  that  are  most  marked,  and  apply  forceps.  How- 
ever, the  dangers  of  tears,  hemorrhage,  and  of  fistulas  communi- 
cating between  the  vagina  and  neighboring  parts  is  such  that  we 
do  not  hesitate  to  have  recourse  to  Cesarean  section,  the  advan- 
tages of  which  are  to-day  so  well  established. 

Even  if  the  stricture  is  tight,  we  follow  the  Cesarean  section 
with  a  subtotal  hysterectomy,  in  order  to  avoid  the  retention  of 
lochia  and  further  pregnancies. 

2.  Vaginal  Atresia. 

Operative  indications  differ  according  as  whether  the  atresia 
is  complicated  by  retention  of  the  menses  or  atresia  without 
retention  or  any  other  complication. 

1.  Menstrual  Retention. — This  condition  most  frequently 
drawls  attention  to  the  malformation  which  is  unnoticed  until 
puberty.  Cases  have  been  published  of  imperforate  hymen  in  a 
quite  young  child  where  accumulation  of  mucus  behind  the 
membrane  has  produced  a  grayish  tumor  which  becomes  promi- 
nent below  the  urethra  when  the  child  cries. 

In  all  cases  where  retention  occurs  behind  an  imperforate 
hymen,  the  indication  is  plain :  let  the  fluid  out. 

The  operation  is  the  simplest  and  consists  in  a  crucial  incision 
of  the  most  protuberant  part  of  the  tumor.  The  great  point  is  to 
take  all  precautions  against  infection,  fatal  septic  complications 
having  frequently  been  observed  and  especially  in  those  cases 
where  a  hematosalpinx  exists.  Before  opening  the  retrohy- 
menal  effusion,  disinfect  very  carefully  the  operative  field.  Then 
empty  the  vagina  and  uterus  as  completely  as  possible  of  clots 
and  tar-like  blood  collections  they  contain.  Douche  thor- 


128 


SURGERY   OF   THE    VAGINA 


oughly  both  cavities  with  sterilized  normal  saline  and  tampon 
with  iodoform  gauze. 

It  is  as  well  to  see  the  case  during  some  months  to  see  that 
there  is  no  reunion. 

When  the  retention  of  the  menses  is  produced  by  an  atresia 
occurring  high  up  in  the  vagina,  the  indication  is  the  same.  We 
must  make  a  route  from  the  cavity  containing  the  fluid  to  the 
exterior.  If  it  consists  of  a  simple  cavity  the  operation  is  easy. 
It  is  quite  sufficient  to  excise  the  obstruction  and  afterward 


FIG.  94. — Hematocolpos  above  a  vaginal  septum. 

reunite  the  walls  of  the  hemorrhagic  pocket,  so  to  speak,  to  the 
inferior  portion  of  the  vagina.  If,  however,  the  occlusion  is  high 
up,  then  the  operation  becomes  more  complex,  and  one  is  forced 
to  make  an  artificial  vagina. 

In  all  these  cases  of  menstrual  retention,  wherever  be  the 
seat  of  the  obstruction,  one  should  examine  into  the  state  of  the 
tubes  and  see  if  they  are  the  seat  of  a  large  dilatation,  because 
rupture  of  these  tubes  has  occurred  after  the  rapid  evacuation  of 
retained  fluid.  Before  operating,  even  in  a  simple  imperforation 
of  the  hymen  one  should  ascertain  by  a  combination  of  a  digital, 
rectal,  and  abdominal  examination  the  presence  of  a  median 


TREATMENT  OF  TUMORS  129 

vagino-uterine  tumor  of  two  or  more  often  one  laterally  placed 
tumor,  which  feels  like  a  hematosalpinx.  If  one  ascertains  the 
presence  of  similar  tumors,  one  should  commence,  and  Veit  is 
very  insistent  on  this  point,  by  opening  the  abdomen  to  see  the 
state  of  the.  adnexa.  The  tubes  are  removed  where  they  are 
much  changed  from  the  normal  and  if  there  exists  a  coincident 
extended  atresia  of  the  vagina.  If,  however,  there  is  a  hope  of 
reestablishing  the  vaginal  canal  and  if  the  tubes  are  not  the  seat 
of  irreparable  lesions,  a  salpingostomy  is  the  usual  procedure. 

2.  Molimen  without  Menstrual  Retention.— If  the  uterus  is 
developed  sufficiently  to  hope  for  a  reestablishment  of  the  genital 
functions,  .then  one  should  attempt  to  make  an  artificial  vagina ; 


FIG.  95. — The  septum  is  resected  and  the  sutures  are  inserted  for  union. 

if,  on  the  contrary,  the  uterus  is  absent  or  very  atrophied,  it  is 
simple  to  have  recourse  to  castration. 

3.  Absence  of  Vagina  without  Complications. — One  is  in  a 
quandary  to  know  if  one  is  authorized  to  allow  a  woman  to  run 
operative  risks  in  order  to  allow  her  to  enjoy  non-fecundant  coitus. 
In  fact,  religious  arguments  have  been  used  against  it.  In  prac- 
tice it  is  certain  that  if  a  woman  bitterly  laments  her  undeveloped 
condition,  the  surgeon  is  authorized  to  make  a  neo- vagina  in  order 
to  allow  her  to  satisfy  her  sexual  instincts. 

3.  Formation  of  a  Neo -vagina.1 

The  first  attempts  at  the  formation  of  a  vagina  have  been  the 
result  of  opening  a  sac  in  cases  of  retained  menses.  Dupuytren, 
in  1817,  after  incision  of  the  perineum,  pushed  his  way  through 

1  Consult    Dumitrescu,  Contribution  a  l'6tude  des  absences  congeliitales   du  vagin 
considerees  au  point  de  vue  chirurgical.     Th.  de  Paris,  1896.    Abram  Brothers,  The 
Construction  of  a  New  Vagina.     Am.  J.  of  Obstetrics,  New  York,  1906,  T.  II,  pp.  289  and 
524.     (In  these  publications  will  be  found  the  majority  of  published  observations.) 
9 


130 


SURGERY   OF   THE    VAGINA 


FIG.  96. — Heppner's  Operation.  An  H-shaped  incision  at  the  level  of  the  diaphragm 
permits  of  tracing  two  flaps  which  clothe  the  anterior  and  posterior  walls  of  the  neo- 
vagina.  The  lateral  portions  are  formed  of  two  lateral  flaps  which  are  twisted  on  their 
pedicle. 


FIG.  97. — Fleming's  Operation.  The  first  flap  consists  of  the  hymen,  the  posterior 
portion  of  the  labia,  and  part  of  the  integuments  of  the  perineum.  Its  base  lies  below 
the  meatus  and  constitutes  the  anterior  wall  of  the  vagina.  A  second  flap  cut  at  the 
expense  of  one  of  the  labia  majora,  with  its  base  anterior  to  the  anus,  forms  the  posterior 
portion. 


TREATMENT  OF  TUMORS 


131 


the  tissues  with  a  blunt  instrument  until  he  came  into  contact 
with  the  collection  of  blood,  which  he  enabled  to  escape.  In 
1823  Vallaume  operated  in  a  similar  manner.  Amussat,  in  1832, 
proceeded  slowly  to  force  back  the  tissues  taking  fifteen  days  to 
reach  the  mejistrual  effusion. 

These  procedures  of  separation  and  pressing  back  of  the  tissues 
certainly  produce  a  cavity,  but  the  difficulty  is  to  maintain  its 
dimensions  sufficient  for  a  neo- vagina. 

For  this  purpose  one  is  forced  to  resort  to  continuous  dilata- 
tion with  tampons,  Gariel  pessaries  and  wooden  or  glass  cylin- 


FIG.  98. — Anderson's  operation. 
Two  flaps.  ABCD  and  ECDF  clothe 
the  anterior  and  posterior  walls  of 
the  neo- vagina.  The  lateral  walls 
are  covered  with  flap  ACG  and  BDH 
formed  in  part  by  the  labia  minora 
which  have  been  split. 


FIG.  99. — Isaac's  operation.  A 
circular  incision  limits  a  flap,  which 
is  gradually  pushed  back  and  conies 
to  act  as  the  fundus  of  the  new  va- 
gina. Its  anterior  portion  will  be 
clothed  with  Thiersch's  grafts. 


ders.     The  results  were  mediocre  and  there  was  always  a  ten- 
dency toward  closing  of  the  cavity. 

In  addition,  in  order  to  obtain  the  dilatation 
which  has  just  been  formed,  resort  has  been  had 
with  epithelium  grafting. 

This  has  been  the  practice  of  the  majority  of 
Heppner  from  1872  was  in  the  habit  of  making 
incision  in  the  middle  of  the  interlabial  diaphragm 
use  of  the  two  flaps  above  and  below  the  transverse 


of  the  cavity, 
to  clothing  it 

gynecologists, 
an  H-shaped 
and  he  makes 
branch  of  the 


132 


SURGERY   OF   THE    VAGINA 


H  in  order  to  cover  the  anterior  and  posterior  walls  of  the  neo- 
vagina.  Two  elliptical  incisions  on  each  side  limit  the  flaps 
which  are  twisted  on  their  pedicles  in  order  to  clothe  sides  of  the 
cavity  (see  Fig.  96) . 

Since  Heppner's  first  operation,  numerous  analogous  ones 
have  been  tried  with  every  variety  of  flap  taken  from  the  neighbor- 
ing parts,  such  as  the  internal  face  of  the  labia  majora  and  rni- 
nora,  genito-crural  region  and  buttocks,  etc.  (Figs.  97  and  98). 

Others  have  simply  put  Thiersch's  grafts,  rolled  on  a  large 
sound,  on  the  raw  surface.  The  sound,  covered  over  with  grafts, 
raw  surface  external,  is  introduced  into  our  cavity  and  fixed  by 
a  suture  (Czempin,  Abbe,  Forgues,  Tuffier).  Grafts  from  the 
labia  have  been  used  (Schalita)  from  the  intestine  of  another  pa- 
tient operated  on  for  artificial  anus  (Kustner),  and  from  the 
mucous  membrane  of  a  rabbit  (Sitsinsky),  from  a  vaginal  pro- 
lapse (Mackenrodt) ,  and  from  the  thigh  (Abbe),  etc. 


FIG.  100. — Dermo-epidermic  grafts  fixed,  denuded  surface  external  on  a  glass  cylinder 

covered  with  rubber. 

But  if  one  uses  simple  grafts  or  has  recourse  to  autoplastic 
strips,  the  cicatrization  of  the  terminal  and  dihedral  angle  leads 
gradually  to  the  effacement  of  the  cavity. 

In  order  to  prevent  contraction  of  this  dihedral  angle,  Isaac 
cuts  a  circular  flap  which  comprises  the  imperforate  part  and 
the  greater  part  of  the  labia  minora  (Fig.  99) .  He  detaches  little 
by  little  the  periphery  of  this  strip  from  the  parts  which  surround 
it;  then  advancing  progressively  toward  the  bladder  anteriorly 
and  posteriorly  toward  the  rectum  he  gradually  pushes  back  this 
flap  deeper  and  deeper  until  it  forms  the  terminal  cul-de-sac  of  the 
neo-vagina.  This  done,  he  supports  it  with  a  glass  tube  closed 
at  the  end.  The  side  of  this  tube  is  clothed  with  a  series  of 
Thiersch  grafts  which  will  form  sides  of  the  artificial  vagina 
(Fig.  100). 

This  method  has  not  been  greatly  followed  and  the  successes 


TREATMENT  OF  TUMORS 


133 


have  been  about  the  same  as  in  those  instances  where  it  has  been 
possible  to  fix  the  flaps  to  the  upper  portion  of  the  genital  canal, 
which  has  been  dilated  by  blood  and  is  still  preserved,  or  to  a 
denuded  cervix  uteri. 

We  believe  that  in  all  cases  of  imperforation  where  it  is 
impossible  to  find  immediately  by  examination  of  the  vulvar 
imperforation  any  perceptible  collection  of  blood  on  the  uterus 
itself,  an  exploratory  *  celiotomy  should  be  resorted  to.  This 
permits  of  finding  out  the  state  of  the  deeper  placed  organs  and 
of  removing  the  hematosalpinx  which  may  be  about  to  burst, 
or  at  least  of  evacuating  its  contents  and  then  of  deciding  if 
it  is  necessary  to  attempt  a  vagino-uterine  reconstitution.  It  has 


FIG.  101. — The  two  dotted  lines  indicate  the  route  to  be  followed,  either  by  the  peri- 
neum from  one  direction  or  the  abdomen  from  the  other  in  order  to  reach  the  vaginal 
fundus  (Vineberg). 

also  the  advantage  of  facilitating  the  finding  of  the  cervix  uteri 
which  one  approaches  from  above  downward.  Sometimes  it  is 
as  well  to  strip  off  the  peritoneum  from  the  anterior  surface  of  the 
uterus  by  the  abdominal  route.  Then  separate  the  uterus  from 
the  bladder  and  open  the  cervical  cavity  in  the  median  line. 
Now  join  the  separation  above  already  commenced  at  the  peri- 
neum and  suture  the  lips  of  the  open  cervix  or  the  existing 
vaginal  fundus  to  the  autoplastic  flaps  stripped  up  from  the 
perineum  (Figs.  101  and  102). 

1  Legueu,  Hartmann,  Tuffier  (Bull,  et  Mem.  de  la  Societc  de  Chir.  de  Paris,  1904,  p. 
592).  Hofmeier,  Zeitsch.f.  geb.  und  Gyn.  Stuttgart,  1904,  T.  LII,  p.  1.  Halban,  Pfan- 
nenstiel,  Sanger,  Wertheim  en  Allemagne,  Vineberg,  Smith  et  Watermann  in  America 
devised  the  preliminary  celiotomy. 


134 


SURGERY   OF   THE    VAGINA 


In  cases  where  a  small  vaginal  fornix  full  of  mucus  was  to  be 
found,  Schwartz1  was  satisfied  to  draw  gradually  the  lips  of  this 
little  cul-de-sac  downward  and  suture  them  to  the  vulvar  incision. 

In  the  absence  of  any  vaginal  fornix,  if  the  uterus  is  accessible 
below,  it  is  possible  by  Polosson's  plan  to  reach  the  cervix  by  the 
lower  route  and  to  fix  it  to  what  remains  of  the  vaginal  or  vestib- 
ular  mucous  membrane.  The  uterus  tending  to  rise,  mobilizes 
this  mucous  membrane  in  a  slow  and  progressive  fashion,  and  the 
result  is  much  better  than  one  could  ever  have  expected.2 

Reconstitution  of  a  Vagina  in  Absence  of  Uterus,  by  the  Supra-symphysial 
Route. — In  absence  of  the  superior  portion  of  the  vagina  and  uterus  C.  Beck3 


FIG.   102. — Operation  terminated,  the  vaginal  fundus  has  been  sutured  to  some  flaps 
stripped  up  from  the  perineum  (Vineberg). 

has  recour.se  to  the  high  route,  but  extraperitoneal  in  order  to  draw  the 
perineal  grafts  into  the  hypogastric  region.  By  a  transverse  supra-sym- 
physial  incision  he  penetrates  the  sub-peritoneal  space,  pushes  back  the 
peritoneum  above  and  separates  the  parts  until  he  is  able  to  make  a  pair  of 
forceps  bulge  into  the  center  of  the  vulva.  With  the  same  forceps  he  draws 
up  above  the  pubis  two  flaps  from  the  thighs  which  he  immediately  sutures, 
above  the  pubis,  to  the  subcutaneous  tissues,  in  such  a  manner  that  their 
cutaneous  surfaces  oppose  and  their  denuded  surfaces  correspond  to  the 
surfaces  prepared. 

Transplantation  of  the  Intestine. — Some  operators  have  borrowed  from  the 
neighboring  intestine  a  segment  sufficient  to  constitute  a  vagina.     Sneguireff4 

'Schwartz,  Revue  de  Gynecologie,  Paris,  1907,  p.  961. 

2  Violet,  Anncdes  de  Gynecologie,  Paris,  1904,  second  series,  T.  I,  p.  742. 

3  Beck,  Annals  of  Surgery,  1900,  T.  II,  p.  572. 

4  Sneguireff,  Zeitsch.  f.  Gyn.,  1904,  XXVIII,  p.  772. 


TREATMENT  OF  TUMORS 


135 


makes  an  incision  along  the  left  border  of  sacrum  and  coccyx,  resects  and 
then  isolates  the  rectum.  He  cuts  through  this  and  the  inferior  portion 
occupies  the  place  of  the  vagina;  the  superior  portion  is  fixed  to  the  place 
left  free  by  the  resection  of  the  coccyx.  Then  splitting  the  perineum  he 
looks  for  the  upper  pocket  of  the  vagina,  opens  it  and  makes  a  communi- 
cation with  the  inferior  rectal  segment. 

Gersuny,1  Fedorow,2  content  themselves  with  covering  the  new  vagina 
with  a  flap  denuded  from  the  anterior  rectal  wall. 


FIG.  103. — A  segment  of  the 
pelvic  colon  resected  by  the  ab- 
domen is  being  drawn  into  the 
denuded  perineo-uterine  portion. 


FIG.  104. — The  continuity  of 
the  colon  reestablished.  One  of 
the  extremities  of  the  resected 
loop  is  fixed  to  the  cervix  and  the 
other  is  closed  (Baldwin). 


Baldwin3  resects  by  the  abdomen  a  segment  of  the  pelvic  colon,  draws 
it  down  into  the  denuded  perineo-uterine  segment  and  then  at  the  end  of 
fifteen  days  destroys,  by  forcipressure,  the  septum  which  separates  the  two 
branches  of  the  loop  and  is  destined  to  constitute  the  neo- vagina  (Figs.  103 
and  104). 

1  Gersuny,  Wien.  med.  Woch.,  1904,  T.  XII,  p.  486. 

2  Fedorow,  Zent.-Bl.  f.  Gyn.,  May  19,  1906. 

3  Baldwin,  Ann.  of  Surgery,  1904,  T.  LX,  p.  398. 


CHAPTER  III. 

PLASTIC  OPERATIONS  ON  PERINEUM  AND  VAGINA. 

Summary. — General    technic    of    plastic    operations. — Treatment    of 
perineal  tears. — Colpo-perineorrhaphy. — Anterior  colporrhaphy. — Narrow- 
ng  of  the  vagina  by  introducing  metallic  suture. — Partitioning  of  the  vagina. 
— Colpectomy. — Treatment  of  recto-vaginal  fistulae. 

The  plastic  operations  practised  on  vagina  and  perineum  are 
numerous  and  procedures  innumerable.  All  have  some  points 
in  common  which  we  will  describe  before  individualizing. 

1.  General  Technic  of  Plastic  Operations. 

1.  Before  the  Operation. — Before  each  operation  empty  the 
intestine,  particularly  in  case  of  inserting  perineal  sutures,  as  the 
evacuation  of  old  scybalous  masses  may  lead  to  tearing  of  the 
sutures.     Purge  the  patient  the  night  before  the  operation  and  on 
the  morrow  give  an  evacuant  enema.     The  preliminary  evacua- 
tion is  followed  by  shaving  of  the  vulva,  vaginal  injections  and  a 
thorough  bathing  with  soap  and  hot  water.     This  constitutes 
the  habitual  pre-operative  treatment. 

There  are  cases  where  this  pre-operative  treatment  should  be 
longer.  For  example,  when  there  is  a  complete  prolapse  of  the 
uterus  with  much  edema  and  ulceration  of  the  vagina  and  cervix 
we  find  it  necessary  before  operating  to  touch  up  the  ulcerated 
areas  with  silver  nitrate  to  reduce  the  prolapse,  to  tampon  the 
vagina  with  iodoform  gauze,  and  only  operate  when  the  cure  is* 
completed. 

2.  During  the  Operation. — The  patient  is  placed  in  the  dorso- 
sacral  position   and   drawn  to  the  edge  of  the  table,  her  gown 
pushed  well  up,  the  thighs  and  knees  flexed  and  enveloped  in  flan- 
nel stockings  and  the  feet  fixed  as  in  Fig.  66. 

The  vagina,  vulva  and  the  skin  of  neighboring  regions  are 
disinfected  by  the  usual  methods.  The  operative  field  is  limited 

136 


GENERAL  TECHNIC  OF  PLASTIC  OPERATIONS  137 

(however. large  the  field  prepared),  a  central  space  showing  for 
the  vulva  and  perineum  surrounded  by  sterilized  compresses 
which  are  held  together  by  small  forceps. 

An  assistant  looks  after  the  anesthesia ;  two  others,  placed  to 
the  right  and^left  of  the  patient,  assist  the  surgeon  who  is  seated 
between  the  patient's  legs.  A  table  furnished  with  his  instru- 
ments is  on  his  right  hand.  An  important  point  is  to  keep 
the  parts  tense  to  which  the  bistoury  is  applied.  To  do  this, 
draw  on  the  neighboring  parts  with  Museux's  little  forceps  or 
may  be  with  tenacula;  these  serve  at  the  same  time  to  fix  the 
limits  of  the  surface  about  to  be  stripped  off. 

In  the  course  of  the  operation  it  is  necessary  to  avoid  lowering 
the  vitality  of  parts  which  are  to  be  united  either  mechanically 
(pulling  on,  contusion,  cutting  too  thin  grafts)  or  chemically  writh 
too  strong  antiseptics  on  rawed  surfaces.  To  this  end,  avoid  con- 
tact with  tampons,  and  to  get  rid  of  blood  irrigate  with  sterile 
water,  saline  of  7  to  1000,  and  at  a  temperature  of  about  38°  C. 

In  order  to  put  in  sutures,  don't   wait   until   the  denuded 


FIG.  105. — Pez/er's  sound. 

sutures  have  dried  up,  but  place  fine  catgut  sutures  on  any  ves- 
sels of  importance. 

Operate  rapidly  covering  completely  the  raw  surfaces  and 
leave  no  virtual  cavity  where  blood  serum  may  collect. 

As  suture  material,  use  catgut  for  buried  sutures,  even  for 
those  placed  in  the  interior  of  the  vagina,  in  order  to  avoid  sepa- 
rating parts  recently  united  in  order  to  search  for  deep  sutures. 
The  non-absorbable  sutures,  silkworm  gut,  silver  wire,  bronze 
aluminium,  do  well  as  perineal  sutures  and  for  those  placed  at  the 
entry  of  the  vulva. 

The  dressing  consists  in  the  introduction  of  an  iodoform  plug 
into  the  vagina,  the  external  portion  being  pressed  back  on  the 
perineum  and  so  leaving  the  urinary  meatus  free.  An  antiseptic 
dressing  is  then  placed  on  the  vulva  externally  and  maintained  with 
a  serviette  disposed  like  a  pair  of  bathing  trunks. 

3.  After  the  Operation. — During  the  first  few  days,  in  the 
case  of  operations  about  the  vulvar  orifice,  it  is  best  not  to  let  the 


138  PLASTIC   OPERATIONS   ON  PERINEUM   AND    VAGINA 

patients  urinate,  but  to  do  an  aseptic  catheterizatien  of  the 
bladder  with  Pezzer's  sound.  The  food  should  be  reduced  during 
the  first  few  days  and  a  dose  of  castor-oil  and  an  enema  should  be 
given  on  the  morning  of  the  third  or  fourth  day.  We  do  not 
advise  prolonged  daily  giving  of  opium.  That  results  in  hard 
accumulations  in  the  rectum  very  difficult  to  get  rid  of.  After 
the  third  or  fourth  day,  we  move  the  bowels  daily. 

On  the  eighth  or  tenth  day  we  remove  the  non-absorbable 
sutures,  carefully  washing  the  parts,  being  careful  to  avoid  pres- 
sure on  the  lines  of  sutures  with  the  cannula  when  the  dressing  is 
removed. 

The  patient  is  confined  to  bed  15  to  21  days  and  abstains 
from  sexual  congress  for  ten  weeks. 

2.  Treatment  of  Perineal  Tears. 

The  treatment  of  perineal  tears  should  be  preventive  and 
curative. 

Preventive  Treatment. — If  the  terminal  part  of  labor  is 
observed,  at  a  given  moment  it  will  be  noticed  that  the  perineum 
which  up  to  now  only  bulged  during  a  pain  remains  distended 
after  the  contraction,  and  the  head  which  appeared  almost  entirely 
enveloped  does  not  go  back  after  the  pain.  If  at  this  moment 
the  accouchement  is  allowed  to  proceed,  the  head  by  a  brusque 
deflexion,  resting  with  its  forehead  on  the  fourchette  and  peri- 
neum, tears  them  both.  It  is  the  brow  which  causes  the  perineum 
to  bulge,  because  it  is  the  part  the  furthest  removed  from  the 
neck  and  corresponds  to  the  greatest  diameter  of  the  head. 

Ancient  accoucheurs  sought  to  arrest  the  expulsion  of  the 
head  in  order  to  give  time  for  the  orifice  to  extend.  This  is  easy 
with  forceps  which  grasp  and  firmly  retain  the  head  but  impossible 
in  the  ordinary  accouchement,  and  the  perineum  will  tear  under 
the  hand  supporting  it.  Varnier  teaches  that  one  should  prevent 
the  forehead  appearing  before  the  parietal  eminences  and  neck 
are  delivered. 

To  do  this  press  with  the  right  thumb  in  the  bregma  which 
has  just  appeared,  arid  thus  stop  the  movement  of  deflexion.  With 
the  thumb  and  index-finger  of  the  left  hand,  he  makes  the  right 
and  left  labia  glide  over  the  corresponding  parietal  eminences 
(Fig.  107).  It  is  only  when  all  the  parts  have  appeared  externally 


TREATMENT  OF  PERINEAL  TEARS 


139 


that  he  allows  slowly  and  progressively  the  deflexion  to  occur, 
allowing  the  forehead,  nose,  mouth  and  chin  to  appear  succes- 
sively.1 This  accomplished,  there  is  no  fear  of  perineal  tear. 

The  little  incisions  in  the  vulva  are  useless  and  only  lead  to 
tears.  If  a  -central  tear  is  feared,  make  an  oblique  incision 
backward  and  outward;  a  median  section  increased  by  the  pas- 


FIG.  106.— Smellie. 

Sagittal  section  of  a  labor  at  the  period  of  expulsion.  The  fetal  head  engages  in  the 
sub-occipito-frontal  circumference.  The  end  of  the  fifth  period  is  near  and  if  it  is 
sudden,  at  the  moment  of  deflexion  the  commissure  will  bulge  forward  and  the  perineum 
will  rupture. 

sage  of  the  fetal  head  risks  the  rupture  of  the  muscular  tissue  of 
the  anus.2 

Curative  Treatment. — In  spite  of  all  prevention  the  perineum 
is  torn.  The  rupture  is  lateral  always,  the  posterior  column 
of  the  vagina,  fibrous  and  resistant,  remaining  intact.  The 
vagina,  skin  and  vulvar  constrictor  being  torn  through,  on 
separating  them  we  get  a  lozenge-shaped  wound  which,  left  to 
itself  to  cicatrize,  results  in  a  perineum  which  no  longer  plays  its 
role  as  a  supporting  agent. 

It  is  therefore  highly  necessary  that  the  ruptures  are  attended 
to  as  rapidly  as  possible,  taking  care  not  to  limit  the  suture  to  the 
skin,  which  would  create  a  perineum  without  any  solidity. 

Immediate  Perineorrhaphy. — This  is  more  or  less  simple 
according  as  the  rupture  is  incomplete  or  complete  regarding  the 

1  Varnier,  La  Pratique  des  accouchement,  Paris,  G.  Steinheil,  1900,  p.  99. 

2  See  before,  Division  of  the  Vulvo- vaginal  Tissues. 


140 


PLASTIC   OPERATIONS   ON   PERINEUM   AND    VAGINA 


anal  canal.  In  these  two  cases,  do  not  hesitate  to  proceed  with- 
out anesthesia,  but  comfort  the  patient  with  encouraging  words. 
In  the  incomplete  rupture  the  operation  is  very  simple. 
Having  first  cleansed  the  parts,  place  an  iodoform  tampon  against 
the  cervix  to  arrest  bleeding  and  hide  the  wound.  Separate  the 
labia  and,  commencing  from  above  down,  place  several  catgut 


FIG.  107. — Means  of  preventing  the  perineal  rupture  (Varnier). 

At  the  moment  when  the  forehead  approaches  the  commissure  distended  to  its  maxi- 
mum, the  thumb  stops  the  deflexion.  The  delivery  (end  of  fifth  period)  begins,  not  by 
progression  of  the  forehead,  but  by  the  retreat  of  the  perineum. 

sutures  in  the  vaginal  tear.  This  tear  often  goes  higher  than  one 
would  think  after  a  simple  external  inspection  of  it.  Then  suture 
the  perineal  rupture  with  silkworm  gut  taking  care  to  include  the 
extremities  of  the  torn  vulvar  constrictor  and  getting  good  con- 
tinuity along  the  length  of  the  wound  and  leave  no  virtual  cavity. 
One  or  two  superficial  sutures  complete  the  operation  if  the  tear 
is  cutaneous.  As  a  dressing,  iodoform  powder  and  swab  of  the 
hydrophile  cotton  which  should  be  frequently  removed  during  the 
first  fe\v  days.  On  the  eighth  or  the  tenth  day,  remove  sutures, 
and  if  no  infection,  cure  is  complete. 

In  the  complete  rupture  the  operation  is  more  complex.     It 


TREATMENT  OF  PERINEAL  TEARS  141 

is  first  necessary  to  close  the  rectal  side  in  order  to  transform  the 
complete  tear  into  an  incomplete  one.  This  is  done  by  passing 
a  series  of  catgut  sutures  which  oppose  the  lips  of  the  rectal 
tear  and  are  applied  from  the  side  of  rectum.  These  catguts  are 
successively  pjaced  from  above  down,  the  most  inferior  compris- 
ing the  sphincter  fibers.  Then  the  vaginal  tear  as  in  incomplete 
ruptures  is  done  with  catgut  and  the  cutaneous  with  silkworm 
gut,  the  most  inferior  stitches  taking  in  the  extremities  of  the 
sphincter  which  is  approximated  as  well  as  possible. 

After  two  days,  give  a  laxative  and  if  necessary  an  enema, 
directing  the  cannula  toward  the  sacrum  and  injecting  the  liquid 
very  gently^  After  this  a  daily  motion  is  indicated. 

With  a  central  rupture  of  the  perineum,  the  best  thing  to  do  is 
to  cut  across  the  perineal  bridge  between  the  rupture  and  the 
fourchette.  Then  the  conditions  are  those  of  an  ordinary  perinea! 
tear  which  is  treated  as  before  described. 

These  immediate  perineorrhaphies  are  put  off  for  some  days  if 
the  patient  is  exhausted  with  a  long  labor,  an  abundant  hemor- 
rhage, or  with  attacks  of  eclampsia.  Again,  if  there  are  very 
extensive  local  injuries  or  violent  contusions  due  to  prolonged 
maneuvers,  in  such  cases  wTe  do  what  is  called  in  France  the 
secondary  immediate  perineorrhaphy1  which  has  only  one  contra- 
indication, viz.,  puerperal  infection. 

After  subcutaneous  injection  of  cocain,  curette  the  wound  and 
suture  as  in  immediate  perineorrhaphy. 

Secondary  Perineorrhaphy. — After  the  fifteenth  day  it  is  impos- 
sible, as  the  immediate  secondary  perineorrhaphy  as  a  part  of  the 
tear  will  be  already  covered  with  cicatricial  tissue.  Verneuil  ad- 
vises rawing  with  a  thermo-cautery,  suturing  the  parts  after 
separation  of  the  scars.  This  is  not  to  be  recommended.  Better 
wait  some  weeks  until  the  tissues  assume  a  definite  appearance, 
then  carry  out  the  late  perineorrhaphy.  Operate  six  weeks  after 
the  accouchement  in  women  who  give  the  breast,  and  after  the 
first  menstruation  in  others. 

Late  Perineorrhaphy. — This  is  practised  several  months  after 
an  accouchement.  We  will  describe  it  later  under  head  of  Colpo- 
perineorrh  aphy . 

1  Tellier,  De  la  p6rin6orraphie  immediate  secondaire.  Lyon  medical,  1895,  T. 
LXXVIII. 


142  PLASTIC   OPERATIONS   ON   PERINEUM   AND    VAGINA 

3.  Colpo-perineorrhaphy. 

Old  procedures,  such  as  Emmet's,  which  aimed  at  replacing 
the  perineum,  have  given  place,  even  in  cases  of  a  simple  tear 
without  prolapse,  to  colpo-perineorrhaph^es.  Truly,  in  a  simple 
perineal  tear  there  is  also  a  tear  of  the  vagina  and  enlargement  of 
its  orifice  and  thus  an  operation  to  be  complete  should  reconsti- 
tute vulva  and  perineum  and  constrict  the  enlarged  inferior 
vaginal  portion. 

A  good  reconstitution  nearly  approaches  the  operation  for 
prolapse.  In  both  cases  a  colpo-perineorrhaphy  is  done.  There 
are  in  operating  great  differences  according  to  the  case  and  it  is 
evident  that  generally  speaking  one  will  not  operate  in  the  same 
fashion  for  the  accidental  tear  of  a  healthy  perineum  as  for  the 
falling  away  entirely  of  all  the  perineal  support  with  prolapse  of 
the  organs. 

In  tears  due  to  injury,  there  are  complete  and  incomplete 
ruptures.  We  will  deal  with  the  treatment  of  incomplete  and 
then  complete  prolapse. 

The  procedures  employed  are  numerous  and  may  be  divided 
into  two  great  categories. 

1.  Operations  by  denudation. 

2.  Operations  by  splitting. 

A.  Colpo-perineorrhaphy  by  Resection. 

The  posterior  column  of  the  vagina  being  rich  in  fibrous 
tissue  is  very  resistant  and  Martin  advises  to  preserve  it  to  serve 
as  a  support  for  the  new  posterior  vaginal  wall  and  only  excising 
the  vaginal  mucous  membrane  laterally.  This  realizes  Emmet's 
new  procedure  which  is  universally  employed  in  America  and 
well  described  in  the  works  of  Baldy  and  Kelly.  The  operation 
presents  modifications  according  to  the  injury  one  is  treating. 

We  will  describe  successively : 

1.  Treatment  of  incomplete  old  tears  of  the  perineum. 

2.  Treatment  of  complete  old  tears  of  the  perineum. 

3.  Treatment  of  uterine  prolapse. 

1.  Old  Incomplete  Perineal  Tears.  First  Stage.  Fix  the 
Limits  of  the  Denudation. — These  limits  are  variable  following 


COLPO-PERINEORRHAPHY 


143 


FIG.  108. — First  procedure  of  Emmet.     (Denudation  in  butterfly  form  with  sutures 

exclusively  perineal.) 


144  PLASTIC   OPERATIONS   OX   PERINEUM   AND    VAGINA 

the  degree  of  relaxation  and  increased  breadth  of  the  vagina 
following  on  the  perineal  tear.  To  fix  them,  place  on  each  side 
at  the  level  of  what  remains  of  the  hymen  two  tenacula.  Be- 
tween them  leave  a  portion  of  the  anterior  vaginal  wall  about 
equal  to  that  of  the  entry  of  a  vagina  in  a  virgin.  A  third  tenacu- 
lum  is  fixed  on  the  posterior  vaginal  column. 

In  drawing  on  these  three  tenacula,  two  grooves  are  created 


Fia.  109. — Placing  the  first  suture,  one  time  the  denudation  terminated.     (Kelly.) 

on  each  side  of  the  middle  line  posteriorly,  which  extend  more  or 
less  deeply  into  the  vagina.  On  the  distal  extremity  of  these, 
place  a  tenaculum  forceps  which  may  be  2  or  4  cm.  (3/4 
inch  to  1  1/2  inches)  from  the  vaginal  entry.  It  is  then  suffi- 
cient to  unite  by  rectilinear  incisions  the  five  points  fixed  by  the 
tenacula  to  produce  the  required  denudation.1 

With  a  bistoury  trace  an  incision  going  from  each  side  of  the 

1  We  use  Museux's  small  forceps  instead  of  tenacula. 


COLPO-PERINEORRHAPHY 


145 


column  of  the  vagina  to  the  distal  tenaculum  and  then  from  this 
tenaculum  to  the  other  which  is  at  the  level  of  the  hymen.  Finally 
unite  with  a  V-shaped  incision,  the  two  tenacula  implanted  on 
the  level  of  caruncules  taking  care  that  the  incision  passes  through 
the  mucous  membrane  and  does  not  impinge  on  the  skin. 

Second  Stage.     Denudation  of  the  Surfaces. — In  order  to  do  the 


FIG.  110. — Placing  the  sutures  on  the  triangle  rendered  accessible  by  drawing  on  the  first 

point  of  suture. 

denudation,  stretch  with  the  aid  of  the  tenacula,  successively,  the 
surfaces  from  the  right  side  and  left  side  and  then  excise  the  vagi- 
nal mucous  membrane  with  a  bistoury  or  Emmet's  curved  scis- 
sors. In  the  latter  case,  the  mucous  membrane  is  raised  in 
the  form  of  little  tongues.  It  is  very  exceptional  to  have  to  tie 
a  bleeding  vessel  as  a  temporary  forcipressure  suffices. 

Third  Stage. — An    assistant   separating   the   right   and    left 
labia  with  tenacula,  the  surgeon,  a  little  below  the  middle  of  the 


10 


146 


PLASTIC   OPERATIONS   ON   PERINEUM   AND    VAGINA 


triangle  of  denudation,  inserts  his  first  silkworm-gut  stitch.  By 
drawing  downward  on  this  stitch  held  between  the  medius  and 
ring-finger,  he  draws  into  view  the  superior  portion  of  the  denuded 
triangle.  He  brings  into  apposition  its  borders  with  catguts 
passed  on  a  strongly  curved  needle.  He  carries  on  the  same  pro- 
cedure from  the  other  side. 

There  remains  now  a  wound  only  moderately  deep,  formed 


FIG.  111. — The  vaginal  sutures  have  been  inserted.     The  perineal  ones  are  inserted  but 

not  tied. 

by  the  reunion  of  the  vulvar  portion  of  the  lateral  triangles  and 
of  the  central  portion  of  the  denudation.  Two  silkworm  guts, 
one  passing  by  the  superior  angle  of  denudation  and  through  the 
posterior  median  column  and  another  uniting  the  skin  below, 
suffice  to  terminate  the  suture.  One  or  two  extra  catguts  between 
the  cutaneous  and  vaginal  sutures,  and  some  superficial  silk- 
worm-gut sutures  unite  the  skin. 


COLPO-PERINEORRHAPPIY 


147 


FIG.  112. — The  tracing  of  the 
denudation. 


FIG.  113. — Insertion  of  the  sutures. 


FIG.  114. — Perineorrhaphy  by  complete  denudation  of  the  perineum  (denudation  and 

insertion  of  sutures). 


14S 


PLASTIC   OPERATIONS   ON   PERINEUM   AND    VAGINA 


Veit's  Procedure. — He  operates  in  rather  a  special  manner.  Departing 
from  the  principle  that  the  perineal  tear  is  most  often  unilateral,  he  makes 
a  circular  incision,  abc,  at  the  junction  of  mucous  membrane  and  skin. 
He  excises  a  paramedian  triangle,  cde,  dissects  up  the  flap  abd,  and  then 
unites  the  points  aed  (which  points  owing  to  the  dissection  of  the  flap  no 
longer  indicate  an  angular  line)  to  dc.  Then  he  brings  together  ab  and  cd. 

This  procedure  is  asymmetrical  like  the  tear;  theoretically  it  would  be 


FIG.  115. — Perineorrhaphy  in  complete  rupture  of  the  perineum  (operation  terminated) 

preferable  to  others,  as  Veit  says,  because  it  is  the  only*  one  which  takes 
into  account  the  anatomy  of  the  rupture. 

2.  Old  and  Complete  Tears  of  the  Perineum. — Before  operat- 
ing some  gynecologists  advise  the  dilatation  of  the  sphincter  as 
much  as  possible  in  order  to  elongate  it  and  prevent  spasmodic 
contractions  which  may  supervene  during  the  first  few  days  fol- 
lowing the  suture. 


COLPO-PERINEORRHAPHY  149 

An  incision  is  made  over  the  recto-vaginal  septum  about  1  cm. 
above  the  line  of  junction  of  the  rectal  and  vaginal  mucous  mem- 
branes. This  line  curved  backward  almost  to  the  level  of  the 
extremities  of  the  torn  sphincter.  This  incision  constitutes 
the  posterior  portion  of  the  denudation,  the  anterior  por- 
tion of  which  is  identical  with  that  which  we  have  described  under 
the  treatment  of  incomplete  ruptures  of  the  perineum. 

Inserting  the  index  finger  into  the  rectum,  the  surgeon  dis- 
sects the  little  band  of  recto-vaginal  septum  which  has  remained 
intact,  in  such  a  manner  as  to  free  it  and  to  press  it  down  below 
like  an  apron  over  the  orifice  of  the  rectum.  A  close  dissection 
enables  us  to  find  without  perforating  the  intestine,  the  two  ends 
of  the  torn  sphincter  and  of  freeing  them  to  the  extent  of  about 
11/2  cm.  It  suffices  then  to  freshen  the  ends  which  are  covered 
with  cicatricial  tissue  to  bring  them  in  apposition  and  then  unite 
them  with  catgut  sutures.  A  few  catguts  inserted  in  figure-of-8 
form  unite  the  deep  parts  in  the  center  of  the  wound  in  such  a 
manner  as  to  avoid  any  cavity. 

Then  do  the  suture  of  the  perineum  and  vaginal  mucous 
membrane  as  in  incomplete  rupture.  The  operation  is  termi- 
nated by  the  suture  of  the  posterior  flap  which  is  like  an  apron  and 
which  hangs  more  or  less  folded  over  the  anus.  In  keeping  these 
last  sutures  long  and  making  a  light  traction  on  them,  one  can 
draw  the  whole  suture  out  and  fix  the  ends  of  the  sutures  on 
the  buttock  with  adhesive  plaster  (Fig.  115). 

3.  Old  Tears  Complicated  by  Prolapse. — In  prolapse  there  is 
as  in  the  incomplete  perineal  tear,  a  gaping  of  the  vulva  and 
insufficiency  of  the  perineal  body.  There  is  also  an  excess  of 
vaginal  wall.  The  operation  ought  to  have  a  triple  object:  to 
diminish  the  posterior  vaginal  wall  and  the  vulva,  and  reconsti- 
tute the  perineum. 

This  can  be  done  by  doing  an  operation  identical  to  that  one 
which  we  have  described  for  the  treatment  of  incomplete  perineal 
tear,  taking  care  that  we  give  to  the  lateral  triangles  of  denuda- 
tion of  the  vagina  considerable  dimensions  in  length  and  breadth, 
so  as  to  resect  a  large  area  of  vaginal  mucous  membrane. 
Dissect  up  almost  entirely  the  lateral  wall  of  the  vagina, 
the  external  border  of  the  triangle  of  denudation  being  parallel, 
and  immediately  subjacent  to  the  angle  which  separates  the 


150 


PLASTIC   OPERATIONS    ON   PERINEUM   AND    VAGINA 


anterior  wall  from  the  lateral.  The  operation  becomes  then  a 
veritable  bilateral  colporrhaphy  combined  with  a  perineorrhaphy. 
The  laxity  of  the  tissues  and  the  presence  of  a  rounded  tumor, 
prominent  anteriorly,  in  place  of  the  posterior  column  of  the 
vagina,  render  this  the  easiest  of  operations. 

Hegar's  Procedure. — The  denudation  has  a  triangular  form.  Dimen- 
sions vary  according  to  the  degree  of  prolapse.  In  slight  cases  it  is  sufficient 
to  denude  a  triangle  having  6  to  7  cm.  breadth  of  base  and  a  height  of  7  cm. 
If 'the  prolapse  is  very  extensive,  the  base  may  measure  8  cm.  and  the  height 
may  be  9. 


FIG.  116. — Hegar's  colpo-perineorrhaphy  (denudation  and  insertion  of  stitches). 

Having  fixed  the  point  at  the  level  of  which  will  be  situated  the  superior 
angle  of  the  wound,  it  is  seized  with  a  small  Museux  forceps  and  drawn  for- 
ward and  upward.  The  posterior  wall  of  the  vagina  appears  directly  in  the 
vaginal  orifice;  two  to  four  other  little  forceps  serve  to  stretch  the  flap  laterally , 
of  which  the  base  is  at  the  level  of  the  fourchette  (Fig.  116).  The  denudation 
is  then  made  with  the  bistoury,  the  point  of  which  is  always  directed  toward 
the  flap.  The  thickness  of  the  flap  varies  according  to  the  state  of  the  tissues. 
In  general  a  few  millimeters  thick  is  enough.  But  when  the  wall  is  hyper- 
plastic,  hard  and  formed  of  only  slightly  vascular  or  cicatricial  tissues,  one 
should  cut  deeper. 

When  the  denudation  is  complete  the  operator  should  make  even  the 
surface  of  the  wound  and  for  this  purpose  he  should  make  the  bleeding  sur- 


COLPO-PERINEORRHAPHY  151 

face  bulge  with  his  finger  in  the  rectum.     If  there  are  any  little  spots  not 
denuded,  remove  them.     The  larger  vessels  are  ligatured  with  catgut. 
The  vaginal  sutures  are  of  catgut  and  the  perineal  of  silver. 

B.  Colpo-perineorrhaphy  by  Division  and  Splitting. 

Langenbeck,  Wilms,  Staude,  Bischoff  were  among  the  first 
to  have  recourse  to  the  splitting  of  the  perineum,  but  these  com- 
plex methods  were  not  inviting;  and  Lawson  Tait  was  the  first 
to  do  a  simple  and  rapid  splitting. 

The  procedure  consists  essentially  in  a  splitting  of  the  peri- 
neum and  recto-vaginal  septum  by  a  transverse  incision  and  in 
reunion  by  following  a  sagittal  line,  antero-posteriorly,  of  the 
denudation  thus  created.  The  wound  reunited  is  perpendicular 
to  the  incision  and  the  perineum  is  reconstituted  between  the 
vulvar  orifice  and  anus. 

1.  Incomplete  Perineal  Tears. — L.  Tait,  with  two  fingers  in 
the  anus,  stretched  the  fourchette  transversely  and  divided  with 
special  scissors,  pointed  and  curved,  the  recto-vaginal  septum, 
stripping  the  right  and  left  sides  over  a  length  of  3.5  to  4  cm.  with 
a  depth  of  2  to  3  cm.  From  the  extremities  of  the  transverse  inci- 
sion he  made  two  others,  which  extended  vertically  upward  on 
the  labium  majora.  Drawing  upward  the  flap  thus  cut,  he 
transformed  the  transverse  wound  into  a  longitudinal  one 
which  he  reunited  by  silver  wires  passed  from  left  to  right,  which 
took  in  all  the  rawed  parts  but  not  the  skin.  This  he  did  in 
order  to  avoid  the  pain  which  these  wires  cause  by  pressure. 

To  this  operation  we  prefer  the  following  which  in  its  main 
lines  recalls  that  of  Doleris'  colpo-perineoplasty. 

The  curved  incision,  with  concavity  above,  is  made  at  the 
union  of  skin  and  mucous  membrane.  Two  fine  Museux's 
forceps  mark  the  limits  already  determined  and  serve  at  the  same 
time  to  stretch  the  parts.  These  are  given  to  two  assistants  who 
draw  on  them  and  the  operator  incises  gently  the  middle  part 
in  a  curve  of  about  3  cm.  The  surgeon  goes  deeper  and  deeper 
until  he  gets  past  the  non  separable  fibrous  zone  whicji  lies  im- 
mediately below  the  skin,  keeping  close  to  the  vagina  in  order  not 
to  risk  injuring  the  rectum.  He  then  presses  back  with  his 
finger  the  tissues  which  deeply  close  the  vagina.  Follow  the 


152  PLASTIC   OPERATIONS   ON   PERINEUM   AND    VAGINA 


FIG.  117. — Perineorrhaphy  incision  by  splitting  in  ruptures  of  the  perineum. 


COLPO-PERIXEORRHAPHY  153 

external  surface  of  the  vagina  until  the  denudation  is  considered 
sufficiently  deep  and  extensive.  Take  a  pair  of  straight  scissors 
and  insert  one  limb  as  deep  as  possible  in  the  lateral  portion  of 
the  separation.  Then  with  one  cut  go  through  the  skin  and 
parts  immediately  subjacent  to  the  right  and  to  the  left  until  the 
incision  marked  by  the  forceps  is  reached.  Then  with  his  finger 
he  completes  the  lateral  denudation  of  the  vagina. 

The  wound  has  the  form  of  a  dihedral  angle  with  base  below 
and  limited  above  by  a  vaginal  valve  and  below  by  a  rectal  valve. 
Taking  off  the  two  forceps  which  mark  the  lateral  limits  of  the 
incision,  they  are  attached  to  the  mid-point  of  these  valves  in 
such  a  manner  as  to  draw  the  vaginal  valve  upward  and  the  rec- 
tal downward  and  to  give  the  wound  the  appearance  of  a  lozenge 
with  the  long  axis  vertical.  Now  insert  sutures;  three  metal 
stitches  (silver,  bronze,  aluminium)  suffice  generally.  The  pos- 


FIG.  118. — Needle  for  perineorrhaphy. 

terior  stitch  passes  through  the  skin  of  the  perineum  in  the  pos- 
terior angle  of  the  lozenge  about  a  centimeter  from  the  edge  of 
the  denuded  surface;  it  then  traverses  the  substance  of  the 
rectal  valve  near  the  upper  end,  care  being  taken  not  to  per- 
forate the  intestine  and  comes  out  opposite  the  point  of  entry. 

The  other  two  stitches  pass  anteriorly  to  the  one  described, 
the  second  at  the  level  of  the  summit  of  the  cleft  and  the  third  in 
the  substance  of  the  vaginal  valve. 

These  wire  stitches  which  pass  easily  on  Emmet's  needle  draw 
the  soft  parts  into  the  median  line.  It  is  thus  necessary  to  pass 
them  laterally  as  deeply  as  possible  in  the  substance  of  the  peri- 
neum, before  insertion  into  the  rectal  and  vaginal  valves. 

The  operation  being  finished  the  result  is  not  esthetic. 
Between  the  vagina  and  anus  is  a  perineum  sufficiently  thick,  but 
anteriorly  the  exuberant  vaginal  mucous  membrane  forms  a  sort 
of  folded  apron  which  projects  over  the  line  of  sutures.  It  is 


154 


PLASTIC   OPERATIONS   ON   PERINEUM   AND    VAGINA 


FIG.  119. — Perineorrhaphy   by  splitting.     The  splitting  has  been  effected  and  the 

stitches  inserted  but  not  tied. 


COLPO-PERINEORRHAPHY 


155 


unnecessary  to  worry  about  this  as  this  mucous  membrane  will 
gradually  contract. 

We  consider  it  useless  to  shave  off  close  to  the  redundant  mucous  mem- 
brane perineum  of  the  posterior  vaginal  wall  and  to  make  a  careful  suture  of 
the  vaginal  flap  to  the  cutaneous  lip. 

2.  Complete  Tear  of  the  Perineum. — In  complete  perineal 
tear  we  should  draw  forward  the  two  extremities  of  the  torn  sphinc- 
ter into  the  median  line.  The  incision  should  be  modified  and 
take  the  form  of  an  H. 


FIG.  120. — Perineorrhaphy  incision  by  splitting  in  complete  ruptures  of  the  peri- 
neum. In  the  skin  can  be  seen  the  little  depressions  corresponding  to  the  extremities 
of  the  torn  sphincter. 

[.To  the  original  incision  for  incomplete  ruptures,  add  two 
incisions  which  run  backward  to  the  level  of  the  torn  sphincter 
denoted  by  a  little  cutaneous  depression. 

The  splitting  and  the  insertion  of  stitches  presents  no  peculiar- 
ity, as  everything  is  done  as  in  incomplete  rupture. 

Some  gynecologists   commence  by  uniting  the   two  lips   of  the  rectal 


156 


PLASTIC   OPERATIONS   ON   PERINEUM   AND    VAGINA 


tear  by  points  of  buried  catgut  inserted  like  Lembert's  sutures  in  intraperi- 
toneal  wounds  of  the  intestine.  They  are  called  after  Lauenstein  and  only 
differ  from  Lembert's  sutures  in  that  they  are  placed  on  intestines  denuded 
of  their  serous  covering.  Analogous  stitches  are  inserted  in  the  vaginal  tear. 
Finish  the  operation  by  a  perineal  suture  of  silver  wire. 

Watkins1  has  recently  advised  an  operation  for  complete  rupture  of  the 
perineum  which  seems  to  him  to  have  the  following  advantages: 

1.  The  sutures  are  away  from  the  anus,  hence  infection  is  diminished. 

2.  There  is  no  tightening  of  skin  or  cicatricial  tissue  about  the  anus. 

3.  The  sphincter  is  sutured  apart. 


FIG.  121. 


FIG.  122. 


4.  There  is  no  danger  of  recto- vaginal  fistula. 

5.  The  post-operative  pains  are  minimal. 

6.  Enemas  may  be  given  without  fear  of  infection. 
The  operation  is  done  in  the  following  manner: 

1.  A  transverse  vaginal  incision  of  a  thumb's  length  and  a  half-thumb's 
breadth  is  made  above  the  most  elevated  portion  of  the  rectal  tear.     The 
higher  the  incision,  the  greater  is  the  security  against  infection.     When  the 
rectal  tear  is  not  extensive,  the  incision  ought  to  be  made  at  least  a  thumb's 
breadth  above  the  edge  of  the  tear. 

2.  With  a  pair  of  pointed  scissors  denude  from  each  side  the  vaginal 
mucous  membrane  until  we  reach  a  point  corresponding  to  the  extremity  of 
the  torn  sphincter  indicated  by  a  depression  in  the  skin  (Fig.  121).     The  same 


Surgery,  Gynecology  and  Obstetrics,  July,  1908. 


COLPO-PERINEORRHAPHY 


157 


FIG.  123. 


FIG.   124. 


FIG.  125. 


FIG.  126. 


158  PLASTIC   OPERATIONS   ON  PERINEUM   AND    VAGINA 

maneuver  is  repeated  on  each  side.     The  limbs  of  the  scissors  are  separated 
in  such  a  manner  as  to  separate  the  tissues  very  thoroughly. 

3.  The  tissue  lying  between  the  two  canals  produced  by  the  scissors  is 
gently  dissected  and  the  finger  explores  to  see  that  no  uncut  bands  remain 
(Fig.  122).     It  is  very  important  to  dissect  thoroughly  the  deep  surface  of  the 
rectal  mucous  membrane,  so  that  when  the  extremities  of  the  anal  sphincter 
are  sutured,  the  sphincter  will  lie  only  on  this  mucous  membrane,  with  the 
result  that  tension  of  the  sutures  will  be  greatly  diminished. 

4.  The  extremities  of  the  sphincter  are  then  seized  on  each  side  with 
pressure  forceps  (Fig.  123).     Draw  out  nearly  the  whole  of  the  muscle.     If 
the  first  hold  is  insufficient,  make  a  second  with  another  forceps  and,  if 
necessary,  a  third. 

5.  The  two  extremities  of  the  muscle  are  sutured  with  chromicized  cat- 
gut which  are  passed  two  or  three  times  through  the  muscle  before  tying 
(Fig.  124).     Include  surrounding  tissue  with  the  muscular  to  avoid  cutting 
through  on  contraction  of  the  muscle. 

6.  Terminate  with  Hegar's  colporrhaphy  (Figs.  125  and  126). 

In  Fig.  126  the  sutures  are  removed  from  the  anal  orifice  and  are  all  in 
the  vagina.  In  rectal  digital  examination  it  is  easy  to  ascertain  a  normal 
muscular  resistance  and  not  the  least  retraction  from  the  skin. 

The  operation  consists,  in  short,  in  a  transplantation  of  tissues.  The 
mucous  membrane,  between  the  inqision  and  rectal  tear,  is  made  to  form  the 
external  face  of  the  perineal  body. 

3.  Old  Tears  Complicated  by  Prolapse. — In  old  tears  compli- 
cated by  prolapse,  the  operation  is  little  different.  The  vagina 
has  suffered  a  considerable  increase  in  size  and  the  perineal 
support  has  more  or  less  disappeared.  We  should  therefore 
resect  a  portion  of  the  vagina  and  make  a  new  perineal  support. 

The  increased  size  of  the  vagina  may  be  corrected  by  any  of  the 
anterior  colporrhaphy  procedures  which  we  will  describe  later. 
If,  however,  we  find  a  well-marked  rectocele  after  splitting  the 
tissues  in  the  usual  way,  it  is  extremely  easy  to  resect  a  more  or 
less  extensive  area  on  the  posterior  vaginal  wall  and  then  to  suture 
with  catgut  the  two  edges  of  the  excised  vagina.  The  operative 
treatment  of  vaginal  prolapse  presents  one  peculiar  point ;  in  place 
of  limiting  our  splitting  to  the  site  of  the  old  tear,  we  should  ex- 
tend as  high  as  the  level  of  the  cervix  uteri,  and  this  is  the 
only  means  of  reconstituting  a  solid  perineal  body. 

The  suture  inserted  in  the  soft  parts  as  formerly  described 
is  here  insufficient.  We  must  not  only  go  deeply  but  some  dis- 


COLPO-PERINEORRHAPHY 


159 


FIG.  127. — On  the  posterior  valve  resulting  from  the  splitting  are  to  be  seen  the  edge  of 

the  levators. 


160 


PLASTIC   OPERATIONS   ON   PERINEUM   AND    VAGINA 


FIG.   128. — Suture  of  the  levators.     (The  posterior  suture  is  tied  but  the  others  are  only 

inserted.) 


COLPO-PERINEORRHAPHY 


161 


FIG.  129. — Resection  of  the  excessive  posterior  vaginal  wall  in  colpo-perineorrhaphy  by 

splitting. 


1 1 


162  PLASTIC   OPERATIONS   ON  PERINEUM  AND    VAGINA 

tance  laterally  in  order  to  bring  between  the  vagina  and  rectum 
more  solid  and  resistant  tissues.  These  tissues  are  principally 
to  be  found  about  the  level  of  the  levators,  and  the  suture  was 
advised  in  1897  by  C.  Noble1  in  America,  by  Ziegenspeck2  in 
Germany,  but  strictly  was  first  practised  in  France  by  Duval  and 
Proust3  and  my  colleague,  Pierre  Delbet.4  We  have  used  it  for 
many  years. 

In  the  case  of  prolapse,  we  must  search  some  distance  away 
for  these  muscles  toward  the  lateral  limits  of  the  denudations. 
They  are  often  hard  to  recognize,  but  on  feeling  with  the  fingers 
the  bands  which  form  the  edges  of  the  preserved  portion  of  these 
muscles,  descending  from  the  superior  portion  of  the  perineum 
backward  from  the  posterior  border  of  the  uro-genital  diaphragm 
to  the  lateral  portion  of  the  rectum.  They  should  be  freed  and 
then,  guiding  one's  needle  with  the  finger,  they  should  be  freely 
sutured  with  chromicized  catgut  very  slightly  resorbent.  Three 
or  four  stitches  are  placed  from  behind  forward  and  then  tied. 

When  a  muscular  perineal  body  is  thus  reconstituted,  the 
skin  and  subjacent  parts  are  sutured  with  non-resorbent  stitches ; 
they  pass|  through  muscles  already  sutured  in  such  a  manner  as  to 
avoid  the,  persistence  of  a  virtual  cavity  between  the  two  rows  of 
sutures  and  thus  prevent  serum  collection. 

In  proceeding  thus,  we  obtain  resistant  perinei  and  durable 
cures. 

In  cases  where  the  excess  of  vaginal  wall  seems  to  indicate  the 
resection  of  a  portion  of  it,  it  is  extremely  difficult  to  do  it.  It  will 
be  found  sufficient  to  remove  a  corner  of  this  wall  and  then  suture 
the  borders  of  this  vaginal  section  before  proceeding  to  the  peri- 
neal reunion  (Fig.  129). 

4.  Anterior  Colporrhaphy. 

The  operative  technic  of  anterior  colporrhaphy  varies  with  the 
object  of  this  operation.  In  the  great  majority  of  cases  it  is 

1  Charles  P.  Noble.     A  Contribution  to  the  Technic  for  the  Cure  of  Lacerations  of  the 
Pelvic  Floor  in  Women.     Amer.  Gyn.  and  Obstet.  Journal,  New  York,  1897,  T.  X,  p.  413. 

2  Ziegenspeck,  Centr.-Bl.  f.  Gyn.,  Leipzig,  1899,  p.  1251. 

3  P.  Duval  and  R.  Proust,  Technique  de  la  suture  des  muscles  releveurs  de  1'anus  au 
cours  de  la  pe'rine'orraphie.     Presse  medicale,  Paris,  November  22,  1902,  p.  1120. 

*  Pierre  Delbet,  Pe'rine'orraphie  par  interposition.     Bull.  etMem.de  laSoc.  de  Chir., 
1902,  p.  1092. 


ANTERIOR  COLPORRHAPHY 


163 

The 


done  for  an  anterior  colpocele  with  concomitant  cystocele. 
following  is  the  operative  procedure: 

Extensive  Anterior  Colporrhaphy  for  Colpo-cystocele. — Com- 
mence by  exposing  and  drawing  on  the  anterior  vaginal  wall  by 
traction  forceps.  A  pair  of  forceps  is  placed  on  the  anterior  lip 


FIG.  130. — Denuded  surface  in  anterior  colporrhaphy. 

of  the  cervix,  which  is  drawn  down  and  back  toward  the  four- 
chette;  with  a  second  forceps,  median  like  the  first,  one  seizes  the 
vaginal  mucous  membrane  immediately  below  the  urethral  mea- 
tus.  Finally,  two  forceps  symmetrically  placed  fix  the  lateral 
vaginal  wall  at  equal  distance  from  the  upper  and  lower  forceps. 


164 


PLASTIC   OPERATIONS   ON   PERINEUM   AND    VAGINA 


After  having  stretched  the  anterior  vaginal  wall,  trace  with  a  bis- 
toury the  elliptical-shaped  flap,  cutting  the  whole  thickness  of  the 
vaginal  mucous  membrane  but  not  interfering  with  the  vesical 
wall.  Then  dissect  up  the  flap,  beginning  at  the  anterior  angle. 
The  commencement  of  the  dissection  at  the  level  of  the  urethral 


FIG.  131. — The  continuous  suture  commences  near  the  cervix.     Hagedorn's  needle  takes 

up  the  denuded  surface. 

wall  is  a  little  delicate  because  the  vaginal  mucous  membrane  is 
bound  to  the  deeper  fibrous  tissue.  But  when  one  reaches  the 
vesico-vaginal  septum,  the  separation  is  easy  and  the  bistoury 
no  lono-er  required.  It  only  remains  to  hook  up  the  free  anterior 


ANTERIOR  COLPORRHAPHY 


165 


part  of  the  flap  with  the  index  finger  and  thumb  of  the  left  hand 
and  denude  by  simply  rolling  back  the  parts  which  separate  easily. 
The  denudation  is  performed  first  in  the  median  line  and  then 
laterally,  until  the  flap  is  quite  detached.  This  method  is  pref- 
erable to  that  of  scissors  or  bistoury.  There  is  less  chance  of 
injuring  the  bladder  because  one  works  in  a  favorable  plane  of 
cleavage,  and  the  hemorrhage  is  less.  It  is  also  more  rapid  which 
is  of  importance  in  anterior  colporrhaphy,  as  generally  it  is  one 
feature  of  a  more  complex  operation. 


FIG.  132. — Anterior  pre-eervical  col- 
porrhaphy. Denuded  surface,  stitches 
are  inserted. 


FIG.  133. — Stitches  tied  with  the  ex- 
ception of  the  last  purse-string  suture 
which  will  close  the  original  center  of  the 
three-branched  star. 


Union  is  obtained  as  in  all  plastic  operations.  The  needle 
should  penetrate  below  the  denuded  surface. 

We  use  catgut  in  place  of  non-resorberit  material  such  as 
silkworm  gut  and  silver  wire,  as  removal  after  contraction  is  so 
difficult,  seeing  that  colporrhaphy  is  so  often  combined  with 
perineorrhaphy.  We  prefer  the  continuous  suture  which  is  more 
rapid.  This  is  done  easily  with  a  medium  Hagedorn's  needle 
which  one  can  take  in  the  hand.  Important  to  remember  is  that 
we  commence  by  the  inferior  extremity  (cervical)  and  progress 
to  the  superior  extremity  (urethral).  The  parts  are  brought 
together  when  sutured  and  the  non-sutured  portion  remains 


166 


.PLASTIC   OPERATIONS   ON   PERINEUM   AND    VAGINA 


easily  accessible.  If,  on  the  contrary,  one  commences  at  the 
urethral  extremity,  the  contraction  of  the  anterior  part  of  the 
vagina  would  interfere  with  the  passage  of  the  sutures. 

Most  often  a  single  suture  plane  is  enough ;  when  the  degree  of 
the  cystocele  has  led  the  operator  to  do  an  extensive  denudation, 
the  tension  of  the  tissues  forces  a  suture  by  stages ;  its  execution  is 
easy.  Begin  with  a  premier  line  of  stitches  which  are  introduced 


FIG.  134. 


FIG.  135. 


and  appear  in  the  denuded  surface,  and  thus  produce  a  fold  of 
the  vesical  wall;  then  one  sutures  the  non-united  parts  above 
this  fold,  taking  up  in  passage  the  deep  plane  to  avoid  cavities 
between  the  two  planes. 

Various  Procedures. — We  have  described  our  operation.     We  ought  to 
add  that  all  sorts1  of  denuded  areas  have  been  described  and  all  manner  of 

1  See  Charles  G.  Child,  in  The  Review  of  Cystocele  in  the  Past  100  Years.     Amer.  J. 
Obstet.,  New  York,  1906,  T.  II,  p.  514. 


ANTERIOR  COLPORRHAPHY 


167 


sutures.     Why   go    into   them  ?     We  consider    these  complicated    sutures 
should  give  way  to  the  simple  continuous  suture  or  that  by  layers. 

Anterior  Pre-cervical  Colponhaphy. — In  some  cases  of  anteflexion  with  col- 
lapse of  the  anterior  vaginal  wall,  forming  at  the  level  of  the  anterior 
fornix  a  prominence,  more  or  less  marked,  which  hides  the  os.  Dole'ris1 
advises  a  little-anterior  pre-cervical  colporrhaphy.  The  denudation  is  tri- 
angular. The  base  corresponds  to  the  angle  of  reflexion  of  the  vagina  on 
the  cervix  and  measures  5-6  cm.  The  sides  have  the  same  length  and 
the  summit  is  about  the  middle  of  the  anterior  vaginal  column.  Unite  each 
of  the  three  angles  by  two  or  three  separated  stitches,  thus  making  a  star  of 


FIG.  136. — Incision  for  the  split- 
ting of  the  urethro-vaginal  septum. 


FIG.  137. — Suture  of  the  levators 
at  the  level  of  the  splitting  of  the 
urethro-vaginal  septum. 


three  branches  and  the  center  is  closed  with  a  pursestring  suture  (Figs. 
132  and  133). 

The  vaginal  portion  of  the  cervix  is  thus  freed  and  a  solid  support  is  thus 
made  below  the  bladder  and  causes  it  to  remain  anterior  to  the  uterus, 
and  supports  it.  It  presses  the  uterus  in  asense  backward  and  helps  to 
overcome  its  anterior  flexion. 

Combination  of  Anterior  Colporrhaphy  with  Amputation  of  the  Cervix. — 
Barton  Cooke  Hirst2  insists  on  this  fact  that  the  uro-genital  diaphragm 
in  prolapse  is  torn  both  anterior  and  posterior  to  the  vaginal  orifice.  He 
recommends  beginning  by  denuding  the  anterior  vaginal  grooves  exactly  as 
the  posterior  are  done  in  colpo-perineorrhaphy.  Insert  sutures  but  do  not 
tie  them  at  once.  Fix  forceps  to  them  and  put  the  forceps  on  the  pubis. 

Draw  the  cervix  out  of  the  vulva  and  make  a  large  denudation  anteriorly 

1  DoleYis,  Treatment  of  Sterility.     Th.  de  Paris,  1898-1899. 

2  Barton  Cooke  Hirst,  A  Contribution  to  the  Efficiency  of  Plastic  Operations  on  the 
Vagina.     Amer.  J.  of  Obstetrics,  New  York,  1905,  T.  II,  p.  100. 


168  PLASTIC   OPERATIONS   ON   PERINEUM   AND    VAGINA 

shaped  like  a  shield  with  base  at  the  cervix  and  the  top  immediately  below  the 
urethral  orifice.  This  flap  is  dissected  up  and  excised  (Fig.  134).  The 
cervix  is  amputated.  Laterally  separate  the  tissues  as  far  as  the  uterine 
ligaments. 

A  continuous  suture  in  several  layers  unites  the  denuded  vaginal  surface; 
the  stump  of  the  cervix  is  sutured  as  in  Hegar's  operation  (Fig.  135),  the 
most  lateral  sutures  taking  up  the  fibro-muscular  tissues  of  the  base  of  the 
broad  ligaments  in  such  a  manner  as  to  obtain  a  firm  hold  of  them.  The 
uterus  is  put  back  in  place  and  the  sutures  inserted  in  the  anterior  grooves 
and  tied. 

Splitting  of  the  Anterior  Wall  of  the  Vagina  and  Suture  of  the  Levators. — 
The  suture  of  the  levators  commonly  practised  to-day  in  colpo-perineorrhaphy 
was  advocated  in  the  treatment  of  hysterocele  by  Delanglade, *  then  by  Groves2 
and  by  Chaput.3  It  is  done  anterior  to  the  vaginal  orifice  and  directly  below 
the  bladder.  This  anterior  repair  of  the  muscular  pelvic  diaphragm  has  the 
advantage  of  placing  the  bladder  on  an  elastic  and  normal  contractile  floor 
and  of  pushing  back  and  up  the  cervix  uteri  and  thus  correcting  the  retro- 
deviation  which  accompanies  prolapse  so  often  (Figs.  136  and  137). 

A  finger's  breadth  behind  the  meatus  make  a  transverse  incision  the  whole 
width  of  the  vagina.  Separate  the  bladder  and  then  search  for  the  levators. 


FIG.  138. — Freund's  operation. 


5.  Constriction  of  the  Vagina  by  Metallic  Sutures. 

Freund4  has  tried  to  obtain   constriction  of   the  vagina   by 
a  series  of  fibrous  rings  around  wires  maintained  some  time  in 

1  Delanglade,  Bull,  et  Mem.  de  la  Soc.  de  Chir.,  Paris,  1902,  p.  1140,  and  1905,  p.  361. 

2  Groves  (Ernest  W.  Hey),  Journal  of  Obstet.  and  Gyn.  of  British  Empire,  1905,  T. 
VII,  p.  187,  et  Ann.  de  gyn.,  Paris,  1905,  p.  367. 

3  Chaput,  Bull.  el.  Mem.  de  la  Soc.  de  Chirurg.,  Paris,  1905,  p.  337. 

4  Freund,  Centr.-Blatt.  f.  Gyn.,  Leipzig,  1893,  p.  1081. 


COLPECTOMY  109 

position.  After  local  anesthesia  he  inserts  his  first  wire  as  in  the 
figure  near  the  insertion  of  vagina  on  the  cervix.  In  doing  this 
he  uses  a  curved  needle  which  is  introduced  into  the  submucous 
tissue  as  far  as  possible.  He  brings  the  needle  out  and  enters 
again  in  the  same  point  and  so  continues  until  the  needle  comes 
out  in  its  original  point  of  entry.  He  now  draws  upon  it  until 
only  a  narrow  vaginal  space  is  left  and  then  ties  it.  The  wire  is 
cut  very  short.  A  series  of  these  sutures  are  placed  from  the 
cervix  to  the  perineum. 

These  sutures  have  a  double  action,  acting  as  mechanical 
irritants  and  finally  a  cicatricial  ring  is  formed. 

6.   Colpectomy. 

Conceived  by  Le  Fort1  and  Neugebauer,2  who  excised  two 
little  quadrilateral  flaps  of  mucous  membrane  on  the  anterior 
and  posterior  walls  and  then  the  union  of  the  denuded  portion 
with  silver  wire  sutures.  This  operation  results  in  a  band  of  no 
great  thickness  which  speedily  gives  way  on  pressure  of  surround- 
ing parts.  The  procedure  of  Dubourg3  who  substitutes  a  trans- 
verse instead  of  antero-posterior  septum  of  the  vagina. 

We  have  modified  the  operation  in  the  following  manner: 

The  prolapse  being  drawn  completely  out  of  the  vulva  we 
excise  on  its  anterior  and  posterior  wall  two  long  and  broad  mu- 
cous membrane  flaps.  Commence  at  the  cervix,  and  terminate 
anteriorly  near  the  meatus  and  posteriorly  near  the  fourchette. 
We  suture  the  twro  denuded  surfaces  with  buried  resorbent 
sutures,  commencing  at  the  cervix  (Fig.  139),  advancing  to  the 
vulvar  orifice,  pushing  back  the  united  tissues  so  that  when  the 
last  stitch  is  put  in,  the  prolapse  is  completely  reduced.  Figs. 
140,  141,  142  show  this  putting  back  of  the  prolapsed  parts  as 
they  are  progressively  sutured. 

We  thus  create  a  long  cicatricial  column  which  occupies  almost 
the  whole  length  of  the  vagina  and  which  is  much  more  efficacious 
than  the  little  mucous  membrane  band  described  by  Le  Fort. 

1  Andr4,   Du  Traitment  du  prolapsus  ut^rin  par    le  proc6d£  de  Le  Fort.     Th.  de 
Paris,  1889. 

2  Neugebauer,  Centr.-Bl.  f.  Gyn.,  1885,  p.  6. 

3  Bordier,  Superiority  des  operations  sur  le  vagin  et  d'une  nouvelle  operation,  en 
particulier  dans  les  prolapsus  ute>ins.     Th.  de  Bordeaux,  1893-1894. 


170  PLASTIC   OPERATIONS   ON   PERINEUM   AND    VAGINA 


FIG.  139. — Anterior  view. 


FIG.   140. — Antero-posterior  section. 


FIG.  141. 


FIG.  142. 


TREATMENT  OF  RECTO- VAGINAL  FISTULAS  171 

Muller1  advised  the  total  removal  of  the  vagina.  The  prolapse 
being  drawn  out  to  a  maximum,  he  then  makes  a  circular  incision 
of  the  mucous  membrane  at  its  base  going  above  the  perineo- 
vulvar  groove  posteriorly,  and  a  centimeter  from  the  meatus 
anteriorly.  From  this  incision  he  strips  the  vaginal  mucous 
membrane  in  its  whole  extent,  amputates  the  cervix,  stops  the 
bleeding  and  inserts  a  series  of  purse-string  sutures  into  the 
denuded  surface,  from  cervix  to  perineum,  pushing  back  the 
tissues  as  they  are  sutured. 

When  the  last  stitch  is  inserted,  close  the  vaginal  entry  with  a 
sagittal  suture.  When  the  operation  is  finished  there  remains  a 
little  cul-de-sac  2  or  3  cm.  deep  which  is  tamponed  with  iodoform 
gauze. 

It  seems  natural  that  secretions  should  form  above  the  cica- 
tricial  column.  That  is  nothing  if  the  operation  is  done  on 
women  after  the  menopause  and  if  the  colpectomy  is  preceded  by 
curettage  and  a  cauterization  of  the  uterine  cavity  with  carbolic 
acid.  Konig2  had  one  death  in  30  cases,  following  infection 
produced  by  pushing  her  hands  into  the  wound  soon  after  the 
operation  was  done.  She  was  old. 

7.  Treatment  of  Recto -vaginal  Fistulas. 

Recto-vaginal  fistulas  present  very  different  anatomical  condi- 
tions. They  may  be  high  or  low,  ostial  or  canal  like.  They  are 
easy  or  difficult  of  access  according  as  where  the  vagina  is  wide 
or  narrow.  The  operations  are  also  very  diverse.  Simple 
cauterizations  are  rarely  successful.  Their  treatment  by  the  rectal 
route  (Demarquay)  or  by  the  sacral  route  (Terrier,  Heydenreich) 
has  been  abandoned  and  now  there  are  two  routes  by  the  vagina 
and  perineum. 

1.  Operations  by  the  Vaginal  Route. — Simple  denudation 
shaped  like  a  funnel,  with  its  summit  at  the  rectum,  followed  by 
reunion  of  a  single  line  of  sutures,  being  careful  not  to  perforate 
the  intestine,  has  given  success.  Schauta  prefers  a  large  triangu- 
lar denudation  with  sutures  at  some  distance.  The  fistula  in 

1  Wormer,  Die  Kolpectomie  zur  Berichtigung  des  Prolapsus  alterer  Frauen.     Mon. 
f.  Geb:  u.  Gyn.,  Berlin,  1898,  T.  I,  p.  367.     Savariaud,  L'ope'ration  de  Muller  pour 
prolapsus.     Annales  de  gynecologic,  Paris,  1906,  p.  660. 

2  Konig,   Miiller's  Method  of  Colpectomy  for  Uterine  Collapse.     Journal  of  Obstet. 
and  Gyn.  of  British  Empire,  1903,  p.  295. 


172 


PLASTIC   OPERATIONS   ON   PERINEUM   AND    VAGINA 


the  center  of  this  large  denuded  surface  is  closed  by  many 
sutures  which  do  not  perforate  the  tissues  in  its  immediate 
vicinity  and  thus  increase  the  chances  of  reunion  (Fig.  143). 


\ 


FIG.   143. — Procedure  by  triangular  denudation. 


Others  have  recourse  to  splitting  of  the  recto-vaginal  septum, 
some    proceed    from    the    fistulous    orifice    (Sanger),   others  to 
do  the  separation  at  some  distance  from  the  fistula   (Doyen). 
In  order  to  prevent  fecal  matters  from  getting  in  between  the 


-U 


FIG.  144. — Procedure  by  splitting  of 
the  septum.  Black  lines  denote  the 
incision,  the  dotted  the  limits  of  the 
splitting. 


FIG.  145. — Procedure  by  splitting.  The 
deep  continuous  suture  is  tied.  The  super- 
ficial placed  but  not  tied. 


opposed  surfaces,  Sanger  makes  a  complementary  rectal  suture. 
After  dilatation  of  the  anus  he  presses  back  the  septum  with  a 
finger  in  the  vagina  in  such  a  manner  as  to  cause  the  fistulous 


TREATMENT  OF   RECTO- VAGINAL  FISTULAS 


173 


FIG.  146.- 


-Denudation   and  limits  of 
flap. 


FIG.  147. — Flap  dissected  and  turned 
back.  The  dotted  line  denotes  the  por- 
tions of  the  ventral  wall  which  will  be 
resected. 


FIG.  148. — The  rectal  wall  is  resected. 
The  sutures  are  placed  but  not  tied. 
When  tied  the  flap  is  raised  up  and  closes 
over  the  denuded  surface  and  fistula. 


FIG.  149. — Section  of 
the  recto- vaginal  septum. 
The  suture  is  tied  on  a  roll 
of  gauze  so  as  not  to  cut 
through.  V,  vagina;  R, 
rectum. 


174  PLASTIC   OPERATIONS   ON   PERINEUM   AND    VAGINA 

orifice,  already  sutured  vaginally,  to  appear  at  the  level  of  the 
anus,  and  he  then  inserts  some  stitches  into  the  rectal  mucous 
membrane  which  he  folds  up  above  the  sutured  fistula. 

Fritsch  and  Le  Dentu  advocate  autoplastic  operations  by  use 
of  a  vaginal  flap,  but  while  Fritsch  takes  this  flap  from  above  the 
fistula,  Le  Dentu  takes  it  from  below  (Fig.  146).  In  the  latter 
case  to  avoid  the  formation  of  a  cul-de-sac  we  should  before 
inserting  the  sutures  resect  a  triangular-shaped  portion  of  the 
rectum,  with  its  summit  at  the  fistula  and  base  corresponding 
to  base  of  the  flap  (Fig.  147). 

Some  stitches,  being  careful  not  to  perforate  the  intestine, 
suture  the  flap  to  the  denuded  surface. 

2.  Operation  by  Perineal  Route. — In  this  operation  we 
commence  by  cutting  through  all  parts  of  the  perineum  subjacent 
to  the  fistula  which  is  either  scraped  or  excised.  We  find  ourselves 
thus  in  the  position  of  dealing  with  a  complete  perineal  rupture 
and  treat  it  accordingly. 

Without  cutting  through  the  perineum  separate  it  up  to  a 
point  just  above  the  fistulous  orifice  and  then  after  suturing  the 
vaginal  and  rectal  orifices  as  in  perineorrhaphy  with  flaps,  leave 
in  a  gauze  drain  which  lies  between  the  perineum  and  rectal  suture. 

In  cases  of  extensive  and  high-placed  fistulas,  Segond  advo- 
cates the  resection  of  a  portion  of  rectum  subjacent  to  the  fistula, 
followed  by  the  drawing  down  of  the  upper  end  which  descends 
like  a  blind  behind  the  vaginal  orifice.  This  latter  is  denuded 
and  sutured  apart  (Figs.  150  and  151). 

Gerard  Marchand's  operation  might  be  applied  to  certain 
recto- vaginal  fistulas.  He  employs  a  certain  technic  for  recto- 
perineal  fistulas  and  this  consists  in  drawing  down  the  rectal 
mucous  membrane  alone  in  front  of  the  fistulous  orifice.  After 
dilatation  of  the  anus,  G.  Marchand1  everts  its  mucous  membrane 
and  incises  it  1  cm.  above  the  ano-cutaneous  line.  He  dissects 
the  mucous  membrane  by  the  aid  of  his  finger  and  the  blunt 
extremity  of  the  scissors.  He  draws  it  down  until  he  is  able  to 
cut  through  it  above  the  fistulous  orifice  and  then  he  attaches 
this  drawn  down  mucous  membrane  to  the  little  collarette  of 
mucous  membrane  preserved  in  the  anal  canal. 

1  Gerard  Marchand,  Perineo-  and  Recto-vaginal  Fistulas.  Treatment  by  Drawing 
Down  of  the  Mucous  Membrane  of  the  Rectum.  Bull.  et.  Mem.  de  la  Soc  de  chir.,  Paris, 
1902,  p.  321. 


TREATMENT  OF   RECTO- VAGINAL  FISTULAS 


175 


FIG.  150. — Segond's  procedure  by  drawing 
down  the  rectum. 


FIG.  151. — Segond's  procedure.    Opera- 
tion terminated. 


FIG.  152. — Legueu's  procedure.  The  perineum  has  been  divided.  The  denuded 
vagina  has  been  split  as  far  as  the  fistula  in  such  a  way  as  to  expose  the  rectal  surface 
plainly. 


176  PLASTIC   OPERATIONS   ON   PERINEUM   AND    VAGINA 

3.  Operation  by  the  Vagino-perineal  Route. — Legueu1  splits 
the  perineum  just  up  to  the  level  of  the  fistulous  orifice,  and  then 
divides  the  denuded  vagina  longitudinally  as  far  as  the  fistula. 
By  this  wound,  which  gapes  widely,  he  sutures  the  rectal  orifice, 
and  then  he  terminates  with  a  colpo-perineorrhaphy  (Fig.  152). 

Indications. — These  various  procedures  we  have  just  de- 
scribed have  different  indications;  each  one  corresponds  to  a 
particular  anatomical  disposition.  For  low-placed  fistulas,  the 
best  thing  to  do  is  the  division  of  the  perineum  followed  by 
its  reconstitution .;  for  high  fistulas,  the  operation  by  the  vaginal 
route.  It  is  very  evident  that  the  state  of  the  perineum  has  as 
much  value  in  the  choice  of  the  operation  as  the  height  of  the 
fistula. 

1  Legueu,  The  Vagino-perineal  Route  in  the  Cure  of  Highly  Situated  Recto-vaginal 
Fistulas.     Presse  medicale,  Paris,  August  26,  1908. 


CHAPTER  IV. 

OPERATIONS  ON  THE  CERVIX  UTERI. 

Summary. — Temporary  or  definite  occlusion  of  the  cervix. — Temporary 
or  definite  trachelotomy. — Courty's  and  Pozzi's  operations. — Trachelor- 
rhaphy  by  denudation  or  flaps. — Amputation  of  the  cervix,  infravaginal 
(with  two  flaps  or  one  flap),  supra  vaginal. — Various  operations  (scarification 
of  the  cervix). — Bouilly's  and  Pouey's  operation. — Operations  for  uterine 
flexions. — Operations  on  the  cervix  and  pregnancy. 

The  operations  on  the  cervix  are  divided  into: 

1.  Operations  to  produce  the  occlusion  of  the  cervix. 

2.  Operations  to  enlarge  the  cervical  canal  (trachelotomy). 

3.  Operations  to  repair   the  torn  cervical  canal    (trachelor- 
rhaphy). 

4.  Amputation  of  the  cervix. 

1.  Occlusion  of  the  Cervix. 

The  occlusion  of  the  cervix  may  be  temporary  or  definite. 

The  temporary  occlusion  may  be  done  with  two  or  three  sutures 
reuniting  the  two  lips  of  the  cervix,  perhaps  with  the  aid  of  two 
Museux  forceps  which  maintain  them  in  contact. 

This  temporary  occlusion  of  the  cervix  is  done  as  prelimi- 
nary to  a  vaginal  or  abdominal  hysterectomy  in  order  to  prevent 
infection  from  a  septic  uterine  cavity.  It  is  also  done  for  a  uterine 
hemorrhage  or  to  maintain  the  provisional  reduction  of  an 
incompletely  reduced  uterine  inversion. 

All  these  indications  are  exceptional  and  in  practice  the  oppor- 
tunity rarely  presents  itself. 

The  definite  occlusion  is  done  by  denuding  the  lips  of  the 
cervix  and  then  uniting  them  by  some  sutures.  It  has  been  done 
in  case  of  vesico-  or  utero-uterine  fistulas  of  a  rebellious  type.  It 
is  a  bad  operation  and  has  been  abandoned. 

12  177 


178  OPERATIONS   ON   THE    CERVIX   UTERI 

2.  Trachelotomy. 

Trachelotomy  or  incision  of  the  cervix  uteri  may  be,  as  in 
occlusion  of  the  cervix,  temporary  or  definite. 

Temporary  trachelotomy  may  be  carried  out  on  the  cervix 
itself  or  on  cervix  and  body  both.  Limited  to  the  cervix  it  consists 
generally  of  a  commissural  incision  which  is  done  with  a  simple 
cut  of  the  scissors. 

If  the  trachelotomy  includes  the  body  of  the  uterus,  one  may 
have  recourse  to  the  incision  of  the  commissures;  one  must  be 
careful  when  at  the  level  of  the  isthmus,  not  to  g%o  beyond  it  on 
the  external  surface  of  the  uterus,  and  even  at  the  level  of  the 
body  to  be  careful  not  to  injure  the  uterine  artery  which  is  so  close 
to  the  border  of  the  uterus. 

Some  operators  prefer  to  the  bi-commissural  incision  the 
antero-median  incision  of  the  organ  after  disinsertion  of  the 
vagina  and  methodical  separation  of  the  bladder. 

Temporary  trachelotomy  may  be  done  during  an  accouche- 
ment in  certain  cases  of  rigidity  of  the  cervix.  .  It  consists  in  a 
commissural  incision,  either  simple  or  bilateral. 

Rejected  by  a  number  of  accoucheurs  who  reproach  this 
incision  as  tending  to  produce  extensive  tears  during  the  passage 
of  the  head,  the  operation  is  rarely  practised.  In  any  case  suture 
the  cervix  as  well  as  possible  after  accouchement. 

It  is  exceptional  to  do  trachelotomy  in  order  to  explore  the 
uterus,  as  simple  dilatation  replaces  it  quite  well.  Again,  incision 
of  the  cervix  is  sometimes  the  indispensable  preliminary  of  a 
myomectomy  per  vias  naturales.1 

Definitive  trachelotomy  aims  at  enlarging  in  a  permanent 
manner  the  orifice  of  the  cervix  constricted  by  an  acquired  or 
congenital  malformation.  Whatever  means  are  employed,  aim 
at  a  new  orifice  of  sufficient  dimensions  and  with  no  tendency  to 
contract. 

That  is  to  say,  reject  trachelotomies  which  only  consist  of 
simple  incisions ;  also  see  that  the  incisions  are  made  with  an 
instrument  comparable  to  the  lithotome,  or  Simpson's  metrotome 
or  Kuchelmeister's  special  scissors. 

Fritsch's  operation  consists  of  a  crucial  incision  of  the  cervix, 

1  See  Vaginal  Myomectomy. 


TRACHELOTOMY 


179 


followed  by  tamponing,  and  twenty-four  hours  after  destroying 
the  points  of  the  flaps  with  the  thermocautery.  This  is  superior 
to  the  aforementioned  procedures  but  is  nevertheless  unworthy 
of  preservation. 

It  is  quite  evident  that  autoplastic  procedures  may  give  a 
definite  enlargement.  They  are  all  based  on  a  general  principle, 
never  to  leave  a  rawed  surface  after  section. 


FIG.  153. — Kiichelmeister's  scissors. 

This  result  is  obtained  in  two  ways:  Courty's  type  aims  at 
covering  the  surface  of  the  section  with  an  autoplastic  flap,  and 
Pozzi's  followers  unite  the  mucous  membrane  of  the  vaginal 
surface  of  the  cervix  to  the  endo-cervical  mucous  membrane. 

Courty's  Operation. — Commence  by  two  triangular  and 
symmetrical  flaps  on  the  cervix,  summit  internally  and  base 
externally.  Each  of  these  flaps  is  limited  by  two  incisions  which 
are  united  at  the  level  of  the  corresponding  commissure  of  the 


FIG.  154. — Dissection  of  two  triangular  and  symmetrical  mucous  flaps, 
cc'o',  bb'o" ;  o,  orifice  of  the  cervia. 

cervix.  These  flaps  are  dissected  down  from  their  summit  to 
their  base,  which  base  is  left  adherent  and  corresponds  to  the 
junction  of  the  cervix  and  the  lateral  vaginal  fornices.  These 
flaps  are  raised  and  their  cervix  is  incised  bilaterally  at  the  level 
of  its  commissures.  The  autoplastic  flaps  are  now  laid  down 
in  the  depressions  thus  created,  and  with  a  catgut  stitch  the 
summit  is  fixed  to  the  endo-cervical  mucous  membrane  at  the 


180 


OPERATIONS  ON  THE    CERVIX   UTERI 


actual  level  of  the  floor  of  the  dihedral  angles  that  represents 
the  incision. 

Additional  sutures  unite  the  anterior  and  posterior  borders 
of  the  flaps  to  the  mucous  membrane  of  the  external  surface  of 


FIG.    155. — A  deep  bilateral  incision  extends  from  the  narrow  orifice  of  the    cervix, 
o,  to  the  middle  of  the  base  of  the  triangular  flaps  cc'o'.  Wo" . 

the  cervix.  The  lateral  incision  of  the  cervical  orifice  is  thus 
covered  with  mucous  membrane  and  no  portion  rests  on  the 
rawed  surface. 


FIG.  156.— The  points  of  the 
flaps  o'o"  are  bent  back  into  the 
angles  of  the  commissural  inci- 
sion  of  the  cervix;  four 
stitches,  two  above  and  two 
below,  fix  the  flaps  in  the  new 
commissures  resulting  from  the 
division. 


FIG.  157. — The  points  of  the  flaps  o' 
o",  pressed  into  the  new  commissures  re- 
sulting from  division,  are  maintained 
there  by  a  button  suture  on  each  side. 
The  operation  is  completed. 


The  idea  of  implanting  a  mucous  flap  in  the  wound  pro- 
duced by  the  division  of  the  stenosed  external  orifice  has  been 
taken  up  by  several  other  operators,  by  Rossner,1  who  cuts  the 
flap  at  a  certain  distance  from  the  external  orifice  (Fig.  158)  and 

1  Rossner,  Cenir.-Bl.f.  Gyn.,  Leipzig,  1897,  p.  210. 


TRACHELOTOMY 


181 


by  Mars1  who  takes  them  like  Courty  from  each  side  of  the 
orifice  (Figs.  159  and  160). 

Pozzi's  Operation. — This  is  known  often  as  stomatoplasty,  and 
is  done  as  follows: 

The  cervix  being  exposed  by  vaginal  specula,  place  on  each 
lip  a  pair  of  bullet  forceps  and  then  with  a  pair  of  strong  scissors 


FIG.  158. — To  the  right  is  seen  the 
resection  of  the  flap,  to  the  left  the  flap 
pressed  back  into  the  commissural  split- 
ting of  the  cervix. 


FIG.  159.— To  the  left  the  flap  has 
been  incised  and  to  the  right  the  flap 
dissected  (Mars). 


FIG.  160. — To  the  left  the  flap  is  raised  up;  to  the  right,  pressed  down  on  the 

denuded  area. 

make  a  bilateral  dicision  of  the  cervix  of  2  or  3  cm.  Dilate  the  cer- 
vical canal  with  Hegar's  bougies  up  to  No.  20  or  30.  This  is 
easy,  owing  to  the  preliminary  splitting  of  the  cervix. 

The  cavity  of  the  cervix  being  then  easily  accessible,  excise 
from  the  lips  two  triangular  prisms,  leaving  a  band  of  mucous 
membrane  in  the  median  line.  Two  or  three  sutures  of  silver 

1  Mars,  Ibidem,  p.  213. 


182 


OPERATIONS   ON  THE   CERVIX   UTERI 


wire  are  sufficient  to  close  the  grooves  thus  created  in  uniting  the 
intracervical  mucous  membrane  to  the  vaginal  (Figs.  161,  162, 
and  163). 

The  operation  when  finished  shows  the  cervix  like  a  duck's 
beak  partly  open,  but  gradually  its  form  changes  by  retraction, 
and  finally  it  comes  to  look  like  a  normal  multiparous  cervix. 

The  dressing  consists  in  placing  a  piece  of  gauze  between  the 
lips  and  in  tamponing  of  the  vagina.  This  is  renewed  every 
two  or  three  days.  The  stitches  are  taken  out  in  five  days. 


FIG.  161. — Commiss- 
ural  excision  of  the  cer- 
vix. First  stage.  Bilat- 
eral division  of  the  cervix. 


FIG.  162. — Second  stage. 
Excision  o  f  triangular 
prism  from  each  side  of 
the  cervical  canal. 


^  FIG.  163.— Third  stage. 
To  the  left  commence- 
ment of  the  suture.  To 
the  right  operation  com- 
pleted. 


3.  Trachelorrhaphy. 

Trachelorrhaphy  is  the  name  applied  to  the  measures  for 
treatment  of  tears  of  the  cervix.  Every  trachelorrhaphy  has  two 
principles:  the  denudation  and  suture. 

Before  beginning  treat  any  inflammatory  lesions  which  may 
exist  and  never  operate  before  their  cure. 

If  the  cervix  is  infiltrated,  everted  and  rigid,  commence  writh 
a  preliminary  treatment,  such  as  hot  injections,  a  scarification  of 
dilated  cervical  follicles,  and  glycerine  tampons.  Only  do  the 
trachelorrhaphy  when  the  cervix  has  become  supple. 


TRACHELORRHAPHY 


183 


As  for  the  perineorrhaphy,  we  find  two  methods;  viz.,  surface 
denudation  and  denudation  by  splitting. 

Trachelorrhaphy  with  Surface  Denudation. — This  is  the 
Emmet  type  of  operation.  It  consists  in  denudation  of  the  tear 
with  excision  of  the  subjacent  scar  and  then  reunion  of  the  rawed 
surfaces. 

The  two  cervical  lips  are  seized  with  two  Museux's  forceps, 
which  drawr  down  the  parts  and  also  separate  them. 

As  it  is  important  to  excise  all  the  cicatricial  tissue,  particularly 
at  the  level  of  the  superior  angle  of  the  tear,  where  there  is  often 
a  rigid  and  fibrous  scar,  it  is  well  to  commence  by  an  incision  at  the 


FIG.  164. — Trachelorrhaphy  by 
denudation.  To  the  left  is  the 
denudation  and  to  the  right  the 
sutures. 


FIG.  165. — Operation  finished. 


level  of  each  angle,  until  one  finds  healthy  subjacent  tissue.  This 
is  done  with  a  pointed  bistoury.  The  denudation  is  accom- 
plished by  the  excision  of  the  flap. 

After  tamponing  to  stop  hemorrhage  unite  the  rawed  sur- 
face with  about  four  catgut  stitches,  passing  through  all  the 
thickness  of  the  cervix  and  tied  externally.  The  suture  is 
commenced  at  the  superior  angle  of  the  wound  and  finishes  at  the 
external  orifice  of  the  cervix.  All  these  sutures  should  be  inserted 
before  tying  them. 

If  the  tear  is  bilateral  repeat  the  same  operation  on  the  oppos- 
ing side  being  careful  to  preserve  in  the  median  line  of  each  lip 
a  band  of  mucous  membrane  about  1/2  cm.  wide  between  the 
lines  of  incision  in  order  to  reconstitute  a  cervical  canal. 


184 


OPERATIONS   ON   THE   CERVIX   UTERI 


Trachelorrhaphy  with  Flaps. — Trachelorrhaphy  with  flaps, 
described  by  Sanger  and  practised  by  Fritsch  and  Kleinwachter, 
is  much  less  employed.  The  triangular  flap,  with  intracervical 
base,  is  cut  at  the  expense  of  the  mucous  membrane  which  covers 
the  tear.  The  resection  is  carried  out  toward  the  cervical  canal, 
and  the  denuded  parts  are  united  (Figs.  166  and  167). 


FIG.  166. — Trachelorrhaphy  with  flaps. 
Dissection  and  raising  of  the  flap  and  in- 
sertion of  sutures. 


FIG.  167. — The  stitches  are  tide  com- 
mencing by  those  furthest  away  from 
the  orifice  of  the  cervix. 


4.  Amputation  of  the  Cervix. 

The  uterine  cervix  is  in  part  supra  vaginal  and  in  part  intra- 
vaginal,  and  the  distinction  of  infra-  and  supravaginal  depends 
upon  whether  the  operation  is  done  below  or  above  a  point  of 
reflexion  of  the  vaginal  mucous  membrane  on  the  cervix,  which 
is  indicated  by  the  difference  of  coloration  of  the  mucous  mem- 
brane as  also  by  the  folded  aspect  of  the  vagina  which  contrasts 
with  the  smooth  cervix. 

A  Infravaginal  Amputations. 

This  was  first  done  in  a  very  rudimentary  manner.  At  first 
the  protruding  portion  was  cut  through  transversely  in  the  vagina. 


AMPUTATION   OF  THE  CERVIX 


185 


Later  the  parts  were  sutured.  Simon  sutured  the  vaginal  mucous 
membrane  above  the  rawed  surfaces,  having  between  the  united 
mucous  membranes  and  the  surface  of  the  section  a  virtual 
cavity.  This  cavity  was  exposed  to  consecutive  hemorrhages 
and  to  an  irregular  cicatrization. 

Hegar  made  great  progress  in  the  operation  by  suturing  the 
vaginal  mucous  membrane  to  the  intracervical. 

To-day  the  most  frequently  practised  is  two-flap  amputation 
or  the  one-flap. 

The  Two-flap  Amputation  (Simon-Marckwald) . — In  this 
operation  which  is  most  applicable  to  large  sclerous  cervices 
without  any  lesion  of  their  lining  surfaces,  a  \vedge-shaped 
excision  with  the  apex  above  is  made  from  each  lip.  The 
operator  now  cuts  through  the  vaginal  surface  of  the  posterior 


FIG.  168. — The  two-flap  amputation  of 
the  cervix.  The  commissures  are  split  bi- 
laterally. From  each  lip  is  excised  a  cunei- 
form segment  of  the  cervix. 


FIG.  169. — Operation  finished. 


lip  from  below  upward  and  from  behind  forward.  After  this 
the  posterior  lip  is  again  incised,  commencing  on  the  intracervical 
surface  and  directing  the  knife  upward  and  backward  until  it 
meets  the  first  incision.  He  thus  excises  a  cuneiform  segment 
of  the  cervix,  wrhich  leaves  two  flaps  facing  each  other's  denuded 
surface  and  covered  on  their  opposing  surfaces,  the  one  by 
intracervical  mucous  membrane  and  the  other  by  the  vaginal 
mucous  membrane. 

Nothing  is  simpler  than  to  suture  the  two  flaps  together 


186 


OPERATIONS   ON   THE   CERVIX   UTERI 


with  a  non-continuous  suture  using  a  strongly  curved  needle. 
The  only  precaution  is  to  pass  the  suture  under  the  denuded 
surfaces  in  order  to  avoid  virtual  cavities  between  the  flaps. 

When  the  operation  on  the  posterior  lip  is  finished,  the  same 
procedure  is  carried  out  on  the  anterior  lip.  It  only  remains 
to  insert  a  suture  in  each  lateral  commissure  and  to  do  the  dress- 
ing which  consists  in  a  light  tamponing  of  the  vagina  \vith  iodo- 
form  gauze  (Figs.  168  and  169). 

The  One-flap  Amputation  (Schroder). — As  usual  the  lesions 
which  demand  operation  are  much  more  marked  on  the  intra- 
cervical  mucous  membrane  than  the  vaginal  surface  of  the 
cervix.  There  is  an  object  in  removing  the  diseased  mucous 
membrane  and  to  cut  a  flap  entirely  at  the  expense  of  the  ex- 
ternal surface  of  the  cervix.  Thus  Schroder's  operation  realizes 


FIG.  170. — One-flap  amputation. 


FIG.  171. — The  flap  is  replaced. 


this  and  it  is  very  commonly  done.  In  this  operation  the  re- 
sected segment  comprises  all  the  intracervical  mucous  mem- 
brane and  the  greater  part  of  the  cervical  tissue  (Figs.  170  and 
171).  It  has  been  advocated  to  make  the  resected  segment 
thicker  in  the  neighborhood  of  the  internal  orifice  of  the  cervix 
than  at  the  other  extremity  so  as  to  give  more  suppleness  to  the 
portion  of  the  flap,  which  ought  to  fold  back  on  itself,  on  the 
surface  of  the  section. 

It  is  simpler  we  believe  to  cut  off  all  the  muscular  tissue  from 
the  flap  and  only  preserve  the  mucous  membrane  on  the  vaginal 
surface.  Thus  we  have  quite  an  elastic  flap  which  applies  itself 
exactly  to  the  rawed  surface  and  which  may  be  fixed  without  fear 
of  the  least  traction  in  the  sutures  (Figs.  172  and  173).  The 
operation  is  done  as  follows: 


AMPUTATION  OF  THE  CERVIX 


187 


The  cervix  having  been  as  a  preliminary  curetted,  so  as  to 
facilitate  the  passage  of  the  suture  needles  and  the  insertion  of 
the  sutures.  Curettage  is  necessary  on  account  of  the  cervical 
metritis  which  usually  exists  and  of  inflammatory  lesions  of  the 
body. 


FIG.  172. — The  flap  is  formed  exclus- 
ively of  the  vaginal  mucous  membrane. 


FIG.  173. — When  the  suture  is  tight  the 
vaginal  mucous  membrance  will  stick  to 
the  section  of  the  cervix. 


After  curettage  draw  the  cervix  down  with  two  Museux 
forceps  applied  to  the  anterior  and  posterior  lips.  Then  incise 
with  single  cuts  of  the  scissors  the  two  commissures  as  far  as 


FIG.  174. — The  cervix  has  been  split  bilaterally.     The  anterior  lip  has  been  excised 
but  the  vaginal  mucous  membrane  has  been  preserved. 

the  vaginal  insertion  and  thus  divide  the  cervix  into  two  so-called 
valves. 

Still  drawing  on  the  posterior  lip  of  the  cervix  forward  and 
upward,  exposed  to  our  view  is  the  vaginal  face  of  the  anterior 


iss 


OPERATIONS   ON   THE   CERVIX   UTERI 


lip.  At  the  level  of  the  free  border  or  a  little  more  externally 
if  the  lesions  encroach  on  the  uterine  orifice,  the  mucous  mem- 
brane is  incised  with  a  bistoury  and  then  separates  off  the 
muscular  tissue  of  the  cervix  until  we  reach  the  point  where  we 
wish  to  make  the  section.  Now  cut  this  through  transversely 
and  then  insert  the  sutures.  Three  catguts  will  suffice.  Do 
not  be  content  merely  to  insert  these  at  the  level  of  the  free 
border  of  the  flap,  but  to  pass  right  through  the  deep  surface, 
even  to  the  surface  of  section  of  the  cervix  in  such  a  manner  as 
to  avoid  a  virtual  cavity  below  the  flap  \vhere  oozing  may  occur 
(Fig.  174).  Pull  the  sutures  tight  to  assure  hemostasis  and  the 


FIG.  175. — Sutures  in- 
serted into  the  anterior  lip 
are  cut  long  and  serve  to 
draw  on  the  cervix,  of  which 
the  posterior  lip  has  been 
excised.  The  vaginal  mu- 
cous membrane  is  preserved. 


FIG.  176. — On  drawing  on  the 
stitches  which  are  purposely 
left  long,  the  right  commissure 
is  exposed  and  in  it  the  sutures 
are  inserted. 


knots  should  be  on  the  outside  of  the  flap  so  as  to  avoid  the 
production  of  little  zones  of  mortification  on  the  line  of  imion. 

The  three  sutures  being  inserted,  keep  them  long  and  put 
on  forceps.  They  serve  as  means  of  traction  while  one  operates 
the  posterior  lip.  The  same  procedure  is  carried  out  on  it 
(Fig.  175). 

Now  all  that  remains  is  suturing  of  the  commissures.  The 
long  sutures  enable  us  to  pull  the  sutured  lips  to  the  right  and 
thus  expose  the  left  commissure.  Also  we  should  trim  the  edges 
of  the  flaps  so  that  there  is  no  overlapping  and  commence  with 
a  posterior  suture  which  traverses  the  muscular  tissue.  The 
same  procedure  is  carried  through  on  the  other  side  (Fig.  176). 


AMPUTATION  OF  THE  CERVIX  189 

In  operating  rapidly  and  under  a  current  of  liquid  antiseptic 
which  an  assistant  directs  in  order  to  carry  away  blood,  the 
different  stages  can  be  executed  without  forceps  or  ligatures. 
Only  exceptionally  has  one  resort  to  these. 

A  drain^is  placed  in  the  cervical  cavity,  the  stitches  cut 
short,  a  last  irrigation  is  made  and  the  parts  are  wiped  with 
sterilized  gauze  while  the  vagina  is  lightly  tamponed  with 
iodoform  gauze. 

The  tampon  is  changed  in  four  or  five  days;  earlier  if  satu- 
rated with  oozing  blood.  After  ten  days  give  vaginal  injections 
arid  as  catgut  sutures  have  been  used,  that  finishes  our  operation. 

In  some  cases  it  is  necessary  to  modify  the  operation  accord- 
ing to  the  seat  and  extent  of  the  lesion.  If  there  are  some  fibrous 
nodules,  or  some  deep  cysts  do  not  hesitate  to  remove  them.  It 
may  even  be  necessary  to  groove  rather  deeply  the  angles  of  the 
lateral  incisions  wrhen  the  tissue  reaches  above  the  vagina. 

These  are  the  minute  precautions  that  one  is  forced  to  take 
which  do  not  complicate  the  operation  and  which  avoid  the 
production  of  pain. 

The  results  are  excellent  and  the  mortality  is  nil.  We  have 
never  seen  any  complication. 

Indications. — Amputation  of  the  cervix  is  suited  to  supra- 
vaginal  hypertrophies,  to  cystic  degenerations,  to  large  inflamed 
sclerosed  cervices.  It  is  also  useful  in  supravaginal  hypertrophy, 
in  cases  of  prolapse;  in  the  last  case  it  is  well  to  separate  the 
bladder  high  up  and  then  excise  the  cervix  freely.  The  suture 
of  the  vaginal  mucous  membrane  to  the  anterior  lip  of  the 
cervix  helps  toward  the  lifting  up  of  the  bladder. 

As  in  a  general  way  the  lesions  in  these  cases  are  most  marked 
in  the  intracervical  mucous  membrane,  this  must  also  be  resected 
high  up  and  it  is  quite  comprehensible  that  one-flap  amputation 
is  superior  to  two-flap  amputation  \vhich  latter  does  not  permit 
of  such  a  high  excision  of  the  intracervical  mucous  membrane. 

B.  Supravaginal  Amputation. 

The  conoid  amputation  of  Huguier  consisted  in  grooving  the 
cervix  by  a  circular  incision  made  belowr  the  insertion  of  the 
vaginal  wall  and  dissected  upward  and  inward  toward  the  cervical 


190  OPERATIONS   ON   THE   CERVIX   UTERI 

canal.  Schroder  substituted  a  more  extensive  operation  which 
permits  of  excision  of  the  whole  cervix  and  even  a  slight  exten- 
sion into  the  surrounding  uterine  tissue. 

1.  Amputation  with  Knife.— After  a  circular  incision  of  the 
vaginal  mucous  membrane,  free  the  cervix  anteriorly  and  pos- 
teriorly, and  anteriorly  detach  the  vagina   by  scraping  the  an- 
terior surface  of  the  cervix  with  the  nail  or  blunt  scissors.      This 
separation   is   at   first   difficult   but   becomes    easier    when    the 
insertion  of  the  vagina  above  has  been  passed.     Above  this  is 
to  be  found  a  cellular  stratum,  inter-utero-vesical,  which  sepa- 
rates easily.     On  reaching  the  uterine  isthmus  desist  from  the 
separation  as  the  peritoneum  may  be  opened. 

Posteriorly  the  vagina  is  separated  from  the  posterior  surface 
of  the  cervix.  As  the  peritoneal  cul-de-sac  descends  just  behind 
the  vagina,  it  is  frequently  opened  during  this  separation.  This 
accident  is  of  little  importance  and  the  breach  can  be  closed 
writh  a  few  catgut  sutures. 

The  cervix  is  now  liberated  in  front  and  behind  and  remains 
attached  only  laterally.  Here  are  inserted  the  broad  ligaments 
and  at  this  level  are  the  numerous  branches  of  the  uterine  artery, 
which  must  be  tied  in  the  tissues.  To  do  this,  pull  the  cervix 
to  the  left  while  an  assistant  separates  the  right  wall  of  the 
vagina  with  a  speculum.  Isolate  with  the  finger  or  grooved 
sound  the  vascular  lamina  and  with  a  blunt  needle  pass  a  suture 
3  or  4  mm.  from  the  uterine  border  at  the  height  of  the  isthmus 
around  the  base  of  the  broad  ligament.  When  tied  the  parts 
are  cut  off  close  to  the  cervix.  The  same  is  done  on  the  other 
side. 

The  isthmus  is  cut  through  with  the  knife,  which  is  directed 
from  above  toward  the  uterine  cavity  in  such  a  manner  as  to 
groove  the  stump  slightly  toward  its  central  part. 

All  that  now  remains  is  to  suture  the  vaginal  to  the  uterine 
mucous  membrane,  taking  up  en  route  uterine  muscle  to  avoid  a 
virtual  cavity.  When  finished  as  the  wound  of  the  vaginal 
mucous  membrane  is  much  more  extended  than  the  opening  of 
the  excised  cervix,  this  mucous  membrane  forms  a  series  of 
folds  which  radiate  from  the  cervical  canal  toward  the  vaginal 
fornices. 

2.  Amputation  with  Galvano -cautery. — In  America,  in  cancer 


AMPUTATION   OF  THE   CERVIX 


191 


of  the  cervix  amputation  with  a  galvano-cautery  is  still  practised. 
Byrne's1  method  is  usually  followed.  A  Leith  forceps  is  intro- 
duced into  the  uterine  cavity  and  serves  to  draw  it  down.  The 
cervix  is  cut  through  with  a  galvano-cautery  and  the  uterine 
cavity  is  curetted  and  cauterized  until  the  surface  is  covered 
\vith  a  black  eschar. 

Later  Byrne  separates  the  cervix  from  the  bladder,  rectum  and 
lateral  attachments  and  then  amputates  with  a  thermo-cautery. 

Most  important  is  to  cauterize  the  wround  often  and  deeply 
as  the  heat's  action  in  cancer  germs  seems  to  extend  beyond  the 


FIG.  177. — Supra  vaginal    amputation.     Trace  of    section    of    cervix.     Point  of    tying 

uterine  artery. 

zone  of  cauterization.  It  is  the  greatest  safeguard  against  a 
return. 

Indications. — Supravaginal  amputation  of  the  cervix  has 
been  above  all  employed  in  cases  of  cancer.  It  is  to-day  gener- 
ally abandoned  for  more  extensive  operations  of  removal.  Cer- 
tain gynecologists,  Spencer  in  England,  advocate  the  igneous, 
so  to  speak,  amputation  of  the  cervix,  with  either  a  galvano- 
cautery  or  a  thermo-cautery  as  being  more  useful  against  a  return 
of  the  cancer  than  the  use  of  the  bistoury. 

The  great  majority  of  surgeons  limit  the  indications  of 
supravaginal  amputation  to  certain  hypertrophic  elongations  of 

1  J.  Byrne,  A  Digest  of  Twenty  Years'  Experience  in  the  Treatment  of  Uterine  Cancer 
by  Galvano-cautery.  Trans.  Amer.  Gyn.  Soc.,  1889,  T.  XIV,  p.  79.  Ibidem,  1891, 
T.  XVI,  p.  172.  Lomer,  Zur  Frage  der  Heilbarkeit  der  Carcinoms.  Zeitsch.  f.  Geb. 
u.  Gyn.,  Stuttgart,  1903,  T.  L,  p.  319. 


192  OPERATIONS   ON   THE   CERVIX   UTERI 

the  cervix  and  uterine  sclerosis.  In  the  latter  case,  the  weight 
of  the  uterus  is  diminished  by  a  good  portion  of  its  length  and 
there  is  a  secondary  contraction  of  the  preserved  parts. 

5.  Various  Operations. 

We  will  now  describe  interventions  carried  out  on  the  cervix 
and  which  do  not  enter  in  any  of  the  operations  we  have  described. 

Scarification  of  the  Cervix. — In  cases  of  endocervicitis,  where  the  finger 
feels  in  the  dilated  cervix  little  granulations,  Dole"ris  advises  the  scarification 
of  the  mucous  membrane  with  a  scarifier  with  multiple  and  parallel  blades,  of 
which  the  length  of  3  to  4  mm.  is  calculated  to  penetrate  just  to  the  glandular 
cul-de-sacs  without  extending  beyond  the  limits  of  the  mucous  membrane. 
This  scarifier  is  applied  progressively  parallel  to  the  axis  of  the  cervix  dilated 
to  its  maximum.  The  most  voluminous  cystic  granulations  are  thus  opened 
and  the  smaller  cut  to  pieces.  When  the  mucous  membrane  is  generally 
incised  with  no  space  between  the  incisions  then  the  mucous  membrane  is 
removed  with  a  little  curette.  This  operation  when  terminated  leaves  a 
smooth  and  united  surface  instead  of  the  cut  up  mucous  membrane  which 
existed  before.  Lavage  with  sublimate  and  tamponing  with  iodoform  gauze 
saturated  with  carbolized  glycerine  25  per  cent,  or  30  per  cent,  iodized 
glycerine  complete  the  operation. 

Bouilly's  Operation. — In  recent  limited  cervical  metritis,  Bouilly's 
operation  may  be  tried.  It  consists  in  excising  from  each  lip  a  flap,  at  the 
same  time  preserving  the  commissures.  The  lip  being  seized  by  its  free 
border  with  a  tooth  forceps,  the  bistoury  is  inserted  into  the  cervical  cavity 
within  the  left  commissure  and  the  incision  directed  anteriorly  toward  the 
anterior  lip  penetrates  into  the  tissue  of  the  cervix  to  the  required  depth;  it 
is  carried  toward  the  right  and  passes  transversely  between  the  mucous  mem- 
brane of  the  vaginal  surface  of  the  cervix  and  the  tooth  forceps  and  then 
before  reaching  the  right  commissure,  it  is  brought  back  toward  the  cervical 
cavity.  With  a  scissors  one  cuts  from  the  substance  of  this  cavity  the  base 
of  the  flap  thus  traced.  A  similar  flap  is  excised  from  the  posterior  lip. 

Each  lip  is  thus  grooved  in  the  cervical  canal.  Preserving  a  band  of 
mucous  membrane  at  the  level  of  each  commissure  suffices  to  prevent  the 
consecutive  atresia. 

As  a  dressing,  Bouilly  introduced  into  the  cervical  cavity  some  iodoform 
gauze,  saturated  with  carbolized  glycerine. 

Pouey's  Operation.1 — This  consists  of  a  circular  resection  of  all  the 
internal  part  of  the  cervix.  As  a  preliminary  dilate  with  Hegar's  dilators 

1  P.  Petit,  Presse  medicale,  Paris,  1901,  p.  238. 


VARIOUS     OPERATIONS 


193 


and  then  make  a  circular  incision  at  the  level  of  the  internal  os.  Then  seize 
the  rauco-rauscular  cylinder  thus  created  and  cut  it  transversely  a  little  below 
the  isthmus.  The  end  of  the  floating  cylinder  of  uterine  mucous  membrane 


FIG.  178.— Circular  resection  of  the  endo-cervical  mucous  membrane. 


FIG.  179. — Operation  for  anteflex- 
ion.  Median  splitting  of  the  poster- 
ior lip. 


FIG.  180. — On  the  right  one  suture 
is  inserted;  on  the  left  the  sutures  are 
tied. 


is  united  by  a  continuous  suture  to  the  mucous  membrane  on  the  external 
surface  of  the  cervix  (Fig.  178). 

Operations  for  Uterine  Flexions. — For  the  simple  incisions  of  the 
posterior  lip  of  the  cervix  practised  by  Sims  and  Emmet  in  uterine  ante- 


ia 


194 


OPERATIONS   ON   THE   CERVIX   UTERI 


flexion,  plastic  operations  have  been  substituted.  In  Dudley's1  operation, 
which  is  particularly  reserved  for  anteflexion,  the  posterior  lip  of  the  cervix 
is  split  in  the  median  line  with  scissors,  and  then  the  intracervical  mucous 


FIG.  181. — Partial  excision  of  the 
anterior  lip,  saving  the  intracervical 
mucous  membrane. 


FIG.  182.— Operation  finished.  The 
external  os  is  enlarged  and  carried 
backward. 


FIG.  183. — Partial  excision  of  posterior  lip;  when  sutures  are  tied  the  uterus  is  corrected. 

membrane  is  sutured  to  the  vaginal  mucous  membrane  on  each  of  the  lips 
of  the  incision  and  at  the  level  of  its  superior  angle,  and  this  results  in  the 
external  os  being  carried  very  far  back  (Figs.  179  and  180).  The  anterior 
lip  is  partially  excised  while  the  external  os  is  preserved.  This  last  excision 
does  away  with  the  hypertrophy  of  the  anterior  lip  so  habitual  in  anteflexion 
(Figs.  181  and  182). 

1  E.  C.  Dudley,  A  Plastic  Operation  Designed  to  Straighten  the  Anteflexed  Uterus. 
Amer.J.  of  Obstetr.,  New  York,  1891,  p.  142. 


OPERATIONS  ON  THE  CERVIX  AND  PREGNANCY 


195 


Reed1  endeavors  to  counteract  anteflexion  by  an  operation  on  the  cervix. 
He  makes,  like  Dudley,  a  vertical  median  incision  in  the  posterior  lip  of  the 
cervix  and  excises  from  each  edge  of  the  incision  a  crescent-shaped  area  of 
tissue.  This  excision  extends  the  whole  length  of  the  incision,  but  preserves 
the  intracervical  mucous  membrane.  Suturing  the  superior  and  inferior 
parts  of  the  excised  areas  together,  the  body  of  the  uterus  is  drawn  up  and 
back  and  this  corrects  the  cervical  canal  (Fig.  183). 

By  his  operation  Nourse,2  on  the  contrary,  remedies  at  will  ante-  and 
retroflexions.  He  splits  the  cervix  laterally  just  to  the  angle  of  flexion  in  such 
a  manner  as  to  completely  separate  the  anterior  lip  from  the  posterior  lip  of 
the  cervix  and  to  be  able  to  make  them  glide,  so  to  speak,  on  each  other;  then, 
after  hysterectomy,  aided  by  traction  on  the  posterior  lip  of  the  cervix,  he 
corrects  the  flexion.  Having  done  this,  he  now  places  forceps  on  each  lip, 
holding  the  posterior  lip  thus  corrected  lower  in  the  vagina  than  the 
anterior.  A  few  sutures  unite  the  edges  of  the  lateral  incision  of  the 
cervix  and  fix  definitely  the  lips  of  the  same  (Figs.  184  and  185). 

In  connection  with  retroflexion,  it  is  the  anterior  lip  that  is  caused  to 
descend  lower  into  the  vagina  than  the  posterior. 


FIG.    184.— Sketch  of  the 
lateral  splitting  of  the  cervix. 


FIG.  185. — The  posterior  lip  has 
been  drawn  into  the  vagina  and 
thus  has  corrected  the '  uterus  and 
it  has  then  been  fixed  in  its  new 
relations. 


6.  Operations  on  the  Cervix  and  Pregnancy. 

Do  operations  on  the  cervix  influence  pregnancy  favorably 
or  unfavorably  ?  We  must  solve  these  questions. 

It  is  certain  that  some  favor  conception  in  doing  away  with 
a  sterility  and  enabling  a  pregnancy  to  proceed  normally.  Such 
operations  as  enlarging  a  stenosed  cervical  orifice  or  curing  a 
rebellious  endometritis.  In  these  operations  it  is  not  doubtful. 

What  is  the  position  in  operations  in  which  a  more  or  less 

1  Charles  A.  Reed,  The  Surgical  Treatment  of  Anterior  Displacements  of  the  Uterus. 
Ibidem,  1892,  T.  L,  p.  12. 

2  F.  P.  Nourse,  An  Original  Operation  for  the  Radical  Cure  of  Uterine  Flexions. 
Ibidem,  1896,  T.  I,  p.  60. 


196  OPERATIONS   ON   THE   CERVIX   UTERI 

extended  excision  has  occurred  ?  This  is  a  much  discussed 
point. 

Observations  on  abortion  and  accouchement  before  term,  on 
rigidities  of  the  os  leading  to  the  death  of  the  fetus,  necessi- 
tating basiotripsy  or  even  leading  to  a  uterine  rupture,  have 
been  published  by  accoucheurs1  (Pinard,  Champetier,  Porak, 
Lepage,  etc.). 

Audebert2  collected  observations  from  sixteen  women  having 
had  amputation  of  the  cervix.  There  were  twenty-two  preg- 
nancies; five  accouchements  at  full  term,  nine  before  term  (at 
6,  7,  7  1/2,  8,  8  1/2  months)  and  ten  abortions  (from  the  first 
to  fifth  month) ;  ten  times  he  observed  premature  rupture  of  the 
membranes.  These  women  had  had  before  operation  twenty-two 
pregnancies  at  term,  two  at  eight  months,  one  at  seven  months, 
and  two  abortions.  The  duration  of  the  gestation  appeared  to 
him  to  be  in  inverse  relation  to  the  height  at  which  the  cervix 
had  been  cut  through  and  the  extent  of  substance  lost. 

These  observations  would  appear  to  lead  to  the  idea  that 
amputations  of  the  cervix  have  a  bad  influence  on  pregnancy 
and  one  ought  therefore  as  much  as  possible  to  avoid  them. 
To  our  idea  this  is  exaggerated.  Consider  an  important  point. 
If  the  uterus  was  operated  on,  it  was  necessary  on  account  of 
sclerous  lesions,  which  of  themselves,  outside  all  surgical  inter- 
vention, might  be  the  cause  of  complications.  Moreover,  when 
accoucheurs'  observations  are  studied,  it  is  remarked  that  the  os 
was  surrounded  by  a  zone  of  cicatricial  tissue  which  was  the 
result  of  an  incomplete  union  of  the  line  of  sutures,  or  an 
operative  fault.  In  certain  cases  the  fault  was  more  pro- 
nounced and  at  the  moment  of  accouchement,  silkworm-gut 
sutures  have  been  found  in  the  cervix,  forgotten  by  the  surgeon. 
If  in  respect  of  observations  made  by  accoucheurs  who  have 
been  struck  by  such  accidents  one  compares  the  statistics  of 
Doleris,  Bouilly  and  ourselves,  the  results  are  quite  different. 
In  certain  cases  sterile  women  have  become  pregnant  after 
amputation  of  the  cervix.  We  can  cite  the  case  of  a  woman 
who  had  never  had  children  and  after  amputation  had  three 
children  successfully. 

1  Discussion  at  the  Society  of  Obstetrics,  Gynecology  and  Pediatrics,  Paris,  1899. 

2  Audebert,  Study  of  Pregnancy  and  Accouchement  after  Amputation  of  the  Cervix. 
Annales  de  Gyn.,  Paris,  1898,  T.  L,  p.  20. 


OPERATIONS  ON  THE  CERVIX  AND  PREGNANCY  197 

In  short,  these  complications  we  have  considered  are  more 
often  the  result  of  badly  done  operations,  of  a  defective  operative 
technic,  or  an  insufficient  asepsis. 

It  is  necessary,  to  avoid  trouble,  to  have  the  new  orifice  wide 
and  to  remain  widely  open,  and  a  primary  union  of  sutures, 
avoiding  any  virtual  cavity  in  which  secondary  secretions  might 
collect. 

Executed  well,  amputation  of  the  cervix  cures  without 
cicatricial  contraction  and  exercises  no  bad  influence  on  the  course 
of  pregnancy.  It  is  also  of  benefit  in  gestation  where  the  vaginal 
portion  of  the  cervix  is  excessively  long.  Operate  it  before  the 
fifth  month  and  give  morphia  immediately  after  the  operation 
to  avoid  the  uterine  contractions  which  might  lead  to  abortion.1 

1  Potocki,  Amputation  of  the  Cervix  during  Pregnancy  in  the  Treatment  of  Hyper- 
trophic  Elongation  of  the  Vaginal  Portion.     Annales  ofGyn.,  Paris,  1906,  p.  709. 


CHAPTER  V. 

LIGATURE  OF  UTERINE  ARTERIES  BY  VAGINAL  ROUTE. 
Summary. — General  anatomy. — Operative  technic. — Indications. 

1.  Anatomical  Notions. 

The  uterine  artery1  is  included  in  the  hypogastric  sheath, 
which  envelops  also  some  vessels  which  run  to  the  uterus  and  to 
the  vagina  and  also  others  going  to  the  bladder  and  ureter. 


A.ul.ov. 


L.uf.8. 


FIG.  186. — Uterine  artery  (posterior  view).     The  uterine  artery  (A.  ut.)  gives  off 
ome    long  cervico- vaginal  branches.    A.   ut.  ov.,   utero-ovarian  artery;    Ur.,    ureter; 
G.  hyp.,  remains  of  the  hypogastric  sheath  containing  the  uterine  artery  and  numerous 
veins;  L.  «/.,  utero-sacral  ligament. 

This  fibrous  and  resistant  sheath  extends  from  the  wall  of 
he  excavation,  where  it  rises  between  the  ilio-pubic  line  and  the 
pine  of  the  ischium  by  a  narrow  root  and  spreads  out  along  the 

1  Fredet,  Vascular  Pedicles  of  the  Uterus.  Ann.  de  Gyn.,  Paris,  1899,  T.  L,  p.  365. 

198 


ANATOMICAL  NOTIONS 


199 


length  of  the  uterus  and  vagina.  It  is  at  the  same  time  a  vas- 
cular sheath,  and  a  powerful  means  of  fixation  described  by  the 
Germans  under  the  name  of  the  cardinal  ligament.  At  a  fair 
distance  from  the  uterus  it  splits  into  two  layers,  the  posterior 
of  which  is  attached  to  the  lateral  parts  of  the  uterus  and  vagina 
\vhile  the  anterior  goes  to  the  bladder  and  terminal  part  of  the 
ureter.  It  is  in  this  latter  part  that  the  ureter  is  to  be  found 


vaq. 

c/ 


R. 

FIG.  187. — Ligature  of  the  vascular  uterine  pedicle  through  the  vagina.  The  utero- 
vaginal  pedicle  seen  from  behind  envelopes  (G.  hyp.) ;  also  the  hypogastric  vessels  and 
their  posterior  extra-pelvic^  branches  (B.p.ext.p.)  which  terminate  at  the  border  of  the 
uterus  and  vagina.  The  uterine  artery  (A.ut.)  enters  the  sheath  from  its  point  of 
origin;  (Ur.),  ureter;  (V),  vagina;  (G.ut.),  vascular  uterine  sheath ;  (G.vag.),  portion  of  the 
pedicle  which  goes  to  the  vagina;  (R.),  rectum  separated  from  the  vagina  and  pressed 
back;  (Cv.),  vascular. 

after  passing  under  the  uterine  artery.  As  a  result  of  this  arrange- 
ment it  is  possible  on  opening  the  anterior  and  posteriorfornices 
of  the  vagina  to  isolate  the  two  sides  of  the  utero-vaginal  lamina. 
On  opening  the  lateral  fornix  the  part  of  this  lamina  attached 
to  the  vagina  has  to  be  separated  containing  as  it  does  the 
vaginal  vessels  from  the  portion  adherent  to  the  uterus  in  which 


200        LIGATURE   OF   UTERINE   ARTERIES    BY   VAGINAL   ROUTE 

are  found  the  uterine  vessels.  When  cut  through  sagittally 
the  uterine  portion  of  the  vascular  pedicle  has  the  form  of  a 
triangle  with  apex  above  and  base  below  (Fredet) . 

2.  Operative  Technic. 

Commence  by  a  circular  incision  through  the  vaginal  mucous 
membrane  around  the  cervix,  and  then  to  this  incision  add  two 
lateral  incisions  which  are  prolonged  on  to  the  lateral  surfaces  of 
the  vagina.  Separate  off  the  vaginal  mucous  membrane  and 
then  the  bladder  from  the  cervix.  Proceed  in  the  same  manner 
posteriorly,  scraping  the  uterine  tissue  with  the  nail.  This 
anterior  and  posterior  freeing  of  the  cervix  enables  us  to  isolate 
more  easily  through  the  lateral  incisions  the  uterine  portion  of 
the  vascular  pedicle  (Fig.  187). 

To  the  right  and  left  of  the  cervix  thus  freed,  cut  through 
the  fibrous  tissues  subjacent  to  the  mucous  membrane  at  a 
height  of  1  cm.  If  this  section  involves  a  branch  of  the  uterine 
artery,  put  forceps  on  it  and  tie  it.  Then,  inserting  a  speculum 
against  the  vaginal  wall  on  the  side  we  operate  and,  drawing 
the  cervix  toward  the  opposite  side,  the  uterine  pedicle  is  ex- 
posed. It  should  be  denuded  upon  both  faces  for  a  distance 
of  several  centimeters.  It  is  easy  to  determine  if  one  has 
overshot  the  uterine  pedicle  by  the  fact  that  the  two  index- 
fingers,  placed  one  in  front  and  one  behind,  are  only  separated 
above  by  a  very  fine  layer  of  cellular  tissue. 

Nothing  is  simpler  than  to  hook  up  the  uterine  pedicle  with 
the  finger  and  to  draw  it  down  and  tie  it  strongly  with  silk 
which  is  passed  on  a  blunt  needle. 

The  two  ligatures  having  been  applied,  close  the  vaginal 
incision  with  catgut  sutures.  The  dressing  is  an  iodoform 
gauze  in  the  vagina. 

In  operating  thus,  one  does  away  with  the  great  part  of  the 
uterine  blood  supply,  the  principal  artery  being  tied  and  the 
circular  incision  in  the  vagina  cuts  off  the  anastomotic  connec- 
tions between  the  strictly  speaking  vaginal  arteries  and  col- 
lateral branches  and  the  uterine  artery  (long  cervico-vaginal 
arteries,  vesical  arteries,  etc.). 


INDICATIONS  201 

3.  Indications. 

These  atrophy-producing  ligatures  were  devised  in  cases  of 
bleeding  fibromata  of  small  or  medium  size.  Combined  with 
removal  of  little  polyps  during  curetting  they  have  given  some 
good  results.  We  have  in  some  cases  had  recourse  to  it.1  To- 
day, when  large  operations  are  much  simpler,  we  believe  they 
may  be  abandoned.  However,  wre  possess  a  means  of  resource 
in  hemorrhagic  fibromata  where,  for  some  reason  or  other,  we  do 
not  wish  to  remove  the  tumor. 

1  Hartmann  and  Fredet,  Ligatures  to  Procure  Atrophy  of  the  Uterus.     Ann.  de  Gyn., 
1898,  T.  L,  pp.  110  and  306. 


CHAPTER  VI. 

REMOVAL  OF  FIBROMATA  BY  THE  VAGINAL  ROUTE. 

Summary. — Removal  of  fibrous  polypi  and  fibromata  of  the  cervix. — 
Transvagino-uterine  myomectomy  (creation  of  a  means  of  access,  explora- 
tion of  the  uterine  cavity,  evacuation  of  fibroma,  treatment  of  the  cavity 
remaining,  after  operative  treatment,  indications). — Transvaginal  myo- 
mectomy. 

The  benign  nature  of  uterine  fibromata  limits  often  their  simple 
encapsulation,  in  a  certain  number  of  diseases  the  operation  can 
be  limited  to  the  removal  of  the  tumor,  which  is  often  enough 
done  by  the  vaginal  route. 

1.  Removal  of  Fibrous  Polyps. 
In  cases  of  simple  fibrous  polyps  situated  on  the  cervix  or 


FIG.   188. — Museux's  traction  forceps. 

coming  out  from  the  interior  of  the  cervix  into  the  vagina,  the 
operation  is  very  simple. 

Anesthesia  is  unnecessary. 

Seize  the  polyp  with  a  strong  traction  forceps .  and  make 
torsion  until  the  pedicle  breaks.  If  the  poly  p.  is  in  the  cavity, 
it  is  often  necessary  to  dilate  the  cervix,  as  a  preliminary,  with 
laminaria  tents.  This  is  rendered  unnecessary  generally  as  the 
tumor  itself  has  produced  the  dilatation.  Seizing  the  cervix  with 
a  traction  forceps  in  order  to  drag  it  down  to  the  vulva,  and 
then  make  torsion  on  the  polyp  and  remove  it  as  stated  above. 

202 


REMOVAL  OF  CERVICAL  FIBROMATA  203 

There  is  no  hemorrhage  to  fear  and  if  some  oozing  takes 
place  the  thermo-cautery  or  iodoform  gauze  suffice  to  stop  it. 

If  the  polyp  is  large  so  that  its  pedicle  emerges  from  beyond 
the  os,  we  must  think  of  a  uterine  inversion  and  not  attempt  to 
remove  it  by^  torsion.  It  is  even  imprudent  to  section  across, 
there  and  then,  that  portion  which  appears  to  be  the  fibroma 
pedicle.  One  is  exposed  to  the  danger  of  cutting  into  uterine 
tissue  and  opening  the  peritoneal  cavity  through  the  inverted 
uterus.  If  a  voluntary  and  methodical  opening  of  the  perit- 
oneum is  regarded,  strictly  speaking,  as  anodyne,  one  cannot 
say  the  same  of  the  involuntary  and  perhaps  ignorant  opening 
of  the  operator.  We  must,  therefore,  avoid  this  accident. 

It  is  done  in  the  following  manner:  Apply  two  traction 
forceps  to  the  fibroma  near  its  free  extremity  and  at  two  sym- 
metrical points  beginning  at  its  extremity  and  split  it  in  the 
median  line.  The  forceps  are  then  removed  and  fixed  on  the 
two  lips  of  the  incision  in  the  fibroma,  causing  it  to  gape.  Then 
proceed  \vith  the  section  until  one  comes  to  the  loose  cap- 
sular  tissue  which  is  met  with  at  the  base  of  implantation  of 
the  tumor.  Nothing  is  simpler  than  to  raise  up  separately 
the  two  halves  of  the  fibroma  without  risk  of  uterine  perfora- 
tion and  thus  shell  them  out  of  their  capsule. 

For  giant  polyps  accompanied  by  gangrene,  removing  them 
in  pieces  is  necessary.  Commence  at  the  center  and  go  toward 
the  periphery,  advance  gradually  and  terminate  by  extirpation  of 
the  pedicle.  The  preliminary  disinfection  by  antiseptic  injec- 
tions for  several  days  following  is  useless.  It  would  be,  in  any 
case,  illusory,  for  it  is  impossible  to  disinfect  the  tissue  of  the 
tumor. 

2.  Removal  of  Cervical  Fibromata. 

If  we  find  a  fibroma  included  in  the  lips  of  the  cervix,  the 
shell  of  uterine  tissue  around  is  freely  incised,  including  even  the 
fibroma ;  then  with  traction  forceps  seize  the  tumor  between  the 
two  lips  of  the  incision  which  encroach  upon  it.  Draw  it  out 
while  with  the  nail  or  a  blunt  instrument  free  it  from  its  capsule. 

In  rare  cases  of  diffuse  fibromata  of  the  cervix,  we  must  do  a 
supravaginal  amputation. 


204 


REMOVAL   OF  FIBROMATA    BY   THE    VAGINAL   ROUTE 


3.  Transvagino -uterine  Myomectomy. 

Devised  by  Velpeau  and  practised  byAmussat,  enucleation 
of  submucous  or  interstitial  fibromata  by  the  vaginal  route  only 
became  general  since  the  publication  of  results  by  Pean,  Segond, 
and  Doyen,  who  have  combined  with  preliminary  hysterectomy 
the  breaking  up  and  enucleation  of  fibromata.1 

1.  Preliminary  Creation  of  Means  of  Access. — For  little 
tumors,  dilate  first  with  laminaria;  generally  one  has  recourse 
to  hysterotomy. 

Doyen  advised  antero-median  hysterotomy  which  is  done 
as  follows : 

After  incision  of  one-half  the  vaginal  circumference,  free  the 


FIG.   189. — Antero-median  hysterotomy.     Two  forceps  fix  the  cervix  and  two  others 
drag  down  and  separate  the  lips  of  the  hysterotomy  incision.     (Doyen.) 

anterior  surface  of  the  cervix  and  the  inferior  part  of  the  uterus. 
Separate  up  the  vagina  at  first,  which  is  a  little  painful,  and  then 
the  bladder.  This  is  easy  owing  to  a  layer  of  cellular  and 
lamellar  tissue  between  it  and  the  uterus — a  layer  which  permits 
easy  cleavage.  If  one  considers  the  separation  high  enough, 
place  a  speculum  between  the  parts  which  so  retains  them. 
Then  draw  down  and  fix  the  cervix  with  two  traction  forceps  in- 

1  See  on  this  question  the  important  monograph  of  Dartigues,  Conservative  Surgery 
of  the  Uterus  and  Adnexa  in  Fibromata.     Th.  de  Paris,  1900-1901,  No.  385. 


TRANS VAGINO-UTERINE   MYOMECTOMY 


205 


serted  into  the  anterior  lip.  Split  in  the  median  line  the  cervix  and 
uterus,  and  then  seize  the  lips  of  the  incision  with  forceps  and 
proceed  in  the  same  way  as  that  we  have  described  at  greater 
length  under  vaginal  hysterectomy. 


FIG.  190. — Segond's  S-shaped  speculum. 


These  forceps  serve  to  draw  down  the  uterus  and  also  to  sepa- 
rate the  lips  of  the  incision.  When  the  uterine  cavity  is  widely 
open,  we  can  attack  the  fibroma  (Fig.  189). 


FIG.  191. — Bilateral  hysterotomy.     The  section  is  higher  internally    than    externally. 


Pean  and  Segond  perform  a  uni-  or  bilateral  splitting  of  the 
cervix  to  the  antero-median  hysterotomy. 

The  patient  being  in  the  dorso-sacral  position,  the  assistant 
to  the  right  lifts  up  the  anterior  vaginal  wall  with  an  S-shaped 


206  REMOVAL   OF  FIBROMATA    BY   THE    VAGINAL   ROUTE 

speculum.  A  second  assistant,  to  the  left,  draws  down  the 
posterior  wall.  The  cervix  is  seized  on  each  lip  by  one  of 
Museux's  forceps  and  drawn  down  to  the  vulva.  Armed  with 


FIG.  192. — Unilateral  splitting  of  the  cervix;  one  can  see  the  fibroma  covered  over 
with  uterine  mucous  membrane  which  has  been  opened  by  the  nail.  (Segond  and 
Dartigues.) 

strong  blunt  scissors,  we  introduce  one  blade  into  the  cervico- 
uterine  canal  and  the  other  into  the  corresponding  fornix.  Cut 
through  each  commissure  up  to  the  isthmus,  encroaching  on 
the  lateral  fornix  of  the  vagina. 


TEA  NS  VAGI  NO-UTERINE  MYOMECTOMY  207 

If,  after  this  double  cervico- vaginal  section,  access  to  the 
cavity  is  still  difficult,  Segond  advises  to  continue  the  incision 
higher,  taking  care  not  to  go  through  the  whole  thickness  of 
the  uterine  border,  but  carrying  the  section  higher  on  the  internal 
surface  than  on  the  external  in  order  to  avoid  injuring  the 
uterine  artery.  The  index-finger  may  complete  the  enlargement 
by  separation. 

Inversely  we  sometimes  only  do  a  unilateral  cervico-vaginal 


FIG.  193. — Segond's  corkscrew. 

hysterotomy.  We  should  limit  ourselves  to  what  is  strictly 
necessary.  It  may,  however,  be  necessary  to  do  the  bilateral 
section. 

2.  Exploration  of  the  Uterine  Cavity. — It  is  useless  if  the 
fibroma  presents  after  splitting  of  the  cervix;  when  the  tumor  is 
deeper,  we  may  explore  the  uterine  cavity  with  the  index-finger 
so  as  to  find  the  exact  seat  of  the  fibroma  and  where  it  is  most 


FIG.   194. — Lanceolated  knife  for  morcellement  of  fibromata. 

accessible.  To  do  this  remove  the  specula  and  draw  down  the 
uterus  with  forceps  which  fix  the  lips  of  the  cervix,  being  aided  by 
the  intrauterine  palpation  of  the  hypogastric  hand  which  presses 
on  the  fundus  of  the  organ. 

3.  Breaking  up  of  the  Fibroma. — When  the  cavity  is  ex- 
plored, the  index-finger  is  placed  in  the  most  accessible  part  of 
the  fibroma,  and  one  tries  to  break  through  the  perifibromatous 
shell  with  the  finger-nail.  Sometimes  it  is  possible  to  imme- 


208 


REMOVAL   OF   FIBROMATA    BY   THE    VAGINAL   ROUTE 


diately  enucleate  the  fibroma  but,  recognized  by  its  blanched 
aspect,  protrudes  like  a  hernia  between  lips  of  the  musculo- 
'mucous  membranous  wound.  In  other  cases,  it  suffices  to 
draw  down  the  fibroma,  with  strong  Museux's  forceps,  or  may  be 
by  a  corkscrew  as  Segond  does.  It  is  well  to  combine  Museux's 
forceps  with  the  corkscrew.  The  forceps  draws  down  the 
fibroma  into  view.  It  is  easy  now  to  insert  the  corkscrew  without 
relinquishing  the  other.  If  the  fibroma  is  small,  enucleate  it; 


FIG.  195. — The  dotted  line  indicates  the  incision  made  by  the  knife  to  cut  the  fibrous 

zone. 

if  large,  break  it  up.  This  latter  is  carried  out  with  the  spirals  of 
the  corkscrew  as  axis  and  base  of  support.  It  should  be  im- 
planted firmly,  but  not  too  well  to  prevent  the  movement  of  the 
knife.  The  left  hand  draws  on  it  gently  and  the  right  takes 
Segond's  knife,  which  we  will  describe.  This  instrument  has 
a  long  handle  and  a  slightly  curved  double-edged  lanceolated 
blade.  It  is  inserted  into  the  fibroma  and  directed  obliquely 
toward  the  extremity  of  the  corkscrew,  until  its  point  just  lies 
below  it.  Then  with  gentle  movements  from  side  to  side,  make 


TRANSVAGINO-UTERINE   MYOMECTOMY 


209 


a  circumduction  of  the  corkscrew  and  bring  it  back  to  its  point 
of  entry.  The  corkscrew  gives  way  to  a  light  traction,  and 
brings  away  with  it  a  conical  fragment  of  the  fibroma.  It  is 
well  before  doing  this  to  insert  a  second  corkscrew  alongside  in 


FIG.   196. — The  corkscrew  is  inserted  too  far  and  the  knife  is  caught  in  the  spirals. 

(Segond.) 

such  a  way  as  to  have  its  hold  prepared  for  the  conoid  mor- 
cellement.  This  is  done  several  times,  as  often  as  necessary  to 
diminish  the  size  of  the  tumor.  While  this  scooping-out  is 
going  on  the  two  lips  are  separated  with  Museux's  forceps  which 


14 


210 


REMOVAL   OF   FIBROMATA    BY   THE    VAGINAL   ROUTE 


act  as  specula.  It  is  useless  to  make  use  of  the  inferior  speculum 
which  serves  to  lower  the  perineum. 

We  have  mentioned  not  to  force  the  corkscrew  in  too  much; 
this  precaution  serves  to  facilitate  the  movement  of  the  knife. 
If  it  is  too  deeply  pressed  in,  it  is  difficult  to  circle  around  its 
point  and  it  gets  entangled  with  the  corkscrew  spirals  (Figs.  195 
and  196). 

When  the  scooping  out  is  advanced  sufficiently  so  that  the 
line  of  capsular  cleavage  is  found  we  can,  with  the  finger, 
produce  movements  of  torsion  and  traction  combined,  and  thus 
produce  the  freeing  of  the  superior  portion  of  the  tumor  which 
comes  into  the  vulva  "en  bloc."  In  other  cases  we  are  forced 


FIG.   197. — Lozenge  morcellement.         FIG.  198. — Ladder  or  Echelle  morcellement. 

to  go  on  slowly  till  the  bitter  end.  Prudence  suggests,  however, 
substituting  the  corkscrew  for  forceps  and  blunt  scissors  in  order 
to  finish  this  last  morcellement.  We  must  also  make  many 
digital  explorations  in  such  a  way  as  to  appreciate  the  different 
consistence  of  the  fibroma  and  uterine  muscle  and  at  the  same 
time  to  learn  the  thickness  of  the  wall  of  fibrous  tissue  capsule. 

In  absence  of  special  instruments,  the  morcellement  may  be 
done  with  traction  forceps  and  scissors. 

It  suffices  to  seize  with  forceps  a  part  of  the  neighboring 
fibroma,  which  one  desires  to  remove,  in  such  a  manner  as 


TRANSVAGINO-UTERINE   MYOMECTOMY 


211 


not  to  lose  hold  and  to  bring  to  the  exterior  of  the  wound  a  part 
of  the  fibroma. 

The  lozenge  morcellement  and  the  shell  variety,  which  Doyen 
has  so  well  described,  are  useful  in  the  scooping  out  of  the  center 
of  the  fibroma. 

All  these  manipulations  do  not  bring  on  a  notable  hemorrhage. 
The  morcellement  is  usually  dry.  The  shell  having  been  emptied, 
the  uterus  retracts  on  itself  and  bleeds  very  slightly. 

4.  Treatment  of  the  Sites  Occupied  by  the  Tumors  and  of  the 
Uterine  Cavity. — After  being  assured  that  the  uterus  has  not  been 


FIG.   199. — Result  of  "ladder"  or  Echelle  morcellement  (after  Doyen). 

perforated,  see  if  there  is  any  hemorrhage.  This  may  cease 
spontaneously  on  retraction  of  the  uterus.  If  not,  apply  forceps 
on  bleeding  points. 

Hemostasis  being  secured,  do  the  postoperative  toilet,  excising 
irregular  and  floating  flaps,  removing  the  clots  and  doing  a  hot 
antiseptic  irrigation. 

Dry  the  parts  and  tamp  on  the  cavity  of  enucleation,  as  also 
the  uterus,  with  gauze  wicks,  one  extremity  of  which  is  left  in 
the  vagina  so  as  not  to  be  forgotten  and  left  in  the  uterus. 

5.  Suture  of  the  Cervix. — This  suture  is  not  always  indicated. 
It  may  be  done  if  the  uterus  has  been  largely  split  or  when  there 


212  REMOVAL   OF   FIBROMATA    BY  THE    VAGINAL   ROUTE 

is  a  hemorrhage  at  the  level  of  one  of  the  lips  of  the  incision ; 
on  the  contrary,  it  is  necessary  to  abstain  from  making  any  union 
when  the  incision  is  not  deep  and  does  not  bleed  and,  above  all,  if 
one  has  been  obliged  to  leave  one  or  more  forceps  on  the  vessels 
in  the  interior  of  the  old  tumor  cavity. 

After-treatment. — The  first  dressing  is  made  from  the  sixth  to 
tenth  day,  unless  infectious  process  oblige  an  early  removal  of  the 
intrauterine  drains. 

The  drains  having  been  removed,  we  can  make  a  hot  intra- 
uterine irrigation,  at  45°  C.,  dry  the  cavity  and  tampon  after- 
ward lightly. 

Indications. — Vaginal  removal  by  morcellement  of  fibromata 
is  indicated  in  cases  where  the  external  face  of  the  organ  has  pre- 
sented a  regular  form  or  where  the  uterus  has  remained  mobile 
and  where  nothing  causes  us  to  suspect  the  existence  of  accom- 
panying lesions  of  the  adnexa. 

4.  Transvaginal  Myomectomy. 

In  transvaginal  myomectomies  the  route  chosen  is  the  vaginal.1 
Colpotomy  anterior,2  without  incision  of  the  peritoneum,  suits 
only  the  removal  of  little  fibromata  which  are  situated  low  down ; 
the  posterior3  to  retro-cervical  fibromata  having  split  the  recto- 
vaginal  septum;  the  lateral4  to  small  intraligamentous  fibromata, 
above  all  to  those  which  have  a  limited  insertion  into  the  border 
of  the  uterus. 

In  all  cases,  after  reaching  the  fibroma  enucleate  it,  with  or 
without  morcellement,  according  to  the  case,  carrying  out  a 
procedure  analogous  to  that  of  intrauterine  myomectomy 
which  we  have  so  lengthily  described. 

1  We  deal  here  only  with  operations  where  there  is  no  opening  of  the  peritoneal 
cul-de-sacs.  We  deal  later  under  colpo-celiotomy  with  the  cases  where  the  peritoneum 
is  opened. 

8  D'HerbScourt,  The  Vaginal  Route  without  Hysterectomy.     Th.  de  Paris,  1900-1901 . 

*  Ott  (D.  de),  Thirteenth  International  Congress  of  Medicine,  Paris,  1900.  Gynecolog- 
ical Section. 

4  Stratz,  Lateral  Colpotomy.     Centr.-Bl.  f.  Gyn.,  Leipzig,  1899,  p.  1106. 


CHAPTER  VII. 

COLPOTOMIES. 

Summary. — Posterior  colpotomy  (operation  results,  indications;  fixing 
the  uterus  in  the  vagina  with  the  fundus  below;  shortening  of  the  utero-sacral 
ligaments;  treatment  of  uterine  inversion). — Anterior  colpotomy  (operation 
modifications  of  technic  according  to  the  case;  opening  of  abscess,  explora- 
tion, removal  of  tumors,  correction  of  uterus,  fixing  uterus  in  vagina  with 
fundus  below,- results,  indications). 

Taken  in  its  most  comprehensive  sense,  colpotomy  signifies 
incision  of  the  vagina.  In  practice  we  limit  the  word  to  incisions 
limited  to  the  vagina,  adding  to  it  a  qualifying  word  if  any  other 
organ  is  implicated  in  the  operation;  for  example,  we  talk  of 
colpocystotomy  when  we  refer  to  the  opening  of  the  bladder 
through  the  vagina. 

The  fundus  of  the  vagina  is  occupied  by  the  uterus,  with  its 
broad  ligaments  enclosing  the  vascular  pedicles;  an  incision  into 
these  lateral  appendages  is  never  made  but  colpotomy  is  either 
practised  in  front  or  behind  the  uterus  and  we  get  the  distinction 
thus  of  anterior  colpotomy  and  posterior  colpotomy. 

1.  Posterior  Colpotomy. 

Generally  posterior  colpotomy  is  not  limited  to  the  vaginal 
wall.  As  the  posterior  vaginal  wall  is  doubled  by  the  peritoneal 
recto-uterine  cul-de-sac,  this  is  also  opened,  hence  in  reality  a 
posterior  colpo-celiotomy  is  practised. 

Operation. — All  preliminary  precautions  to  vaginal  operations 
having  been  taken,  a  broad  short  speculum  is  placed  on  the 
posterior  vaginal  wall,  depressing  and  drawing  down  the  four- 
chette  with  it.  Seize  the  posterior  lip  of  the  cervix  with  traction 
forceps  and  draw  down  the  cervix  and  lift  it  strongly  forward. 
This  manipulation  results  in  stretching  the  posterior  fornix 
which  is  well  drawn  back  by  the  vaginal  speculum.  The  in- 
cision is  made  with  the  scalpel.  In  no  case  is  it  permitted  to 

213 


214 


COLPOTOM1ES 


employ  the  trocar  in  spite  of  the  arguments  of  the  Lyons  school 
and  several  German  gynecologists  in  favor  of  this  instrument.1 
We  discountenance  its  employ  because  it  is  blunt  and  may  injure 
the  rectum,  sometimes  united  with  the  posterior  fornix.  There- 
fore the  scalpel  is  used  to  incise  the  vaginal  wall.  A  trans- 


FIG.  200. — Posterior  colpotomy.  A  speculum  draws  down  the  posterior  wall  of  the 
vagina  and  a  pair  of  forceps  draws  the  cervix  forward.  The  dotted  line  represents  the 
incision  in  the  mucous  membrane  of  the  vagina  reflected  in  the  cervix. 

verse  incision  cuts  through  the  vaginal  wall  and  even  encroaches 
on  the  cervix  which  serves  as  a  sort  of  executioner's  block.  How- 
ever tempted  one  may  be  to  incise  the  prominence  of  the  posterior 
vaginal  wall,  it  must  not  be  done. 

1  Recently  Fraenkel  advocated  puncture  because  the  scalpel  causes  hemorrhage  and 
also  because  the  pocket  automatically  cannot  be  reached  from  a  distance.  Fraenkel, 
Die  vaginale  Incision.  Arch.  f.  Gyn.,  Berlin,  1907,  T.  LXXXIII,  p.  171.)  None  of 
these  objections  is  valid. 


POSTERIOR  COLPOTOMV  215 

The  vagina  when  incised  may  present  one  of  three  aspects: 

1.  A  collection  in  the  posterior  fornix  which  bulges  forward. 

2.  A  collection  although  situated  low  down  may  not  press 
back  the  dome  of  the  vagina. 

3.  Or  the  collection  is  situated  high  up,  being  several  centi- 
meters from  fhe  posterior  fornix  of  the  vagina. 

Colpotomy  is  only  a  preliminary  to  a  more  complex  operation 
(removal  of  adnexa,  of  a  fibroma  from  the  posterior  surface  of 
the  uterus,  etc.). 

In  the  first  case,  simple  incision  of  the  posterior  fornix  gives 
immediate  vent  to  the  contents  of  the  recto-uterine  pouch. 

•  In  the  second,  we  must  search  for  the  pouch  and  to  do  so 
must  proceed  in  a  methodical  manner.  The  posterior  wall  of  the 
uterus  as  guide,  the  index-finger  slowTly  separates  off  the  tissues  and 
remains  in  contact  \vith  the  wall  until  it  reaches  the  level  of  the 
collection.  It  is  no\v  best  to  insinuate  the  finger  into  the  angle 
which  is  formed  between  the  uterus  and  the  retro-uterine  pouch. 
Then  having  penetrated  into  this  angle,  by  directing  the  finger 
backward  we  burst  the  pocket  and  give  vent  to  its  issue. 

When  the  collection  is  situated  high  up,  some  centimeters 
above  the  fornix,  its  localization  is  more  difficult.  We  must 
remember  that  the  pockets  which  are  situated  high  up  are 
more  often  juxta-median  than  absolutely  median.  After,  there- 
fore, working  in  the  median  line  of  the  posterior  surface  of  the 
uterus,  one  should  direct  the  examination  toward  the  affected  side. 
In  these  cases  place  one  hand  on  the  abdomen  and  this  presses 
down  the  tissues.  This  hand  helps  to  guide  the  pocket  toward 
the  index-finger.  In  the  course  of  the  search  for  a  suppurative 
collection,  situated  deeply,  it  sometimes  happens  that  pockets 
of  serous  contents,  more  or  less  abundant,  are  opened.  The 
eruption  of  this  serous  fluid  into  the  field  of  operation  should  not 
lead  one  to  think  that  the  operation  is  finished.  Their  existence 
really  confirms  the  existence  of  a  subjacent  suppurating  pocket 
and  should  lead  one  to  go  on  with  the  search  until  it  is  found. 
Be  careful  to  alwrays  keep  in  touch  with  the  uterus  so  as  to 
avoid  injuring  a  loop  of  intestine. 

The  pocket  having  been  opened,  its  contents  flow  out  without 
any  difficulty.  There  are,  however,  cases  of  old  hematocele 
where  the  blood  in  solid  clots  should  be  evacuated  with  the  finger 


216  COLPOTOMIES 

or  a  blunt  curette.  One  might  be  tempted  to  irrigate  the  pocket; 
we  do  not  advise  these  irrigations  which  are  more  dangerous  than 
useful. 

Finally,  the  operation  is  finished  by  the  insertion  of  a  drain. 
We  can  make  a  special  cross  drain  by  running  a  small  one 
through  a  larger  and  fixing  with  a  suture.  This  will  not  then 
fall  out  so  easily.  However,  an  ordinary  drain  will  do  if  we  fix  it 
to  the  posterior  lip  of  the  cervix  \vith  a  silkworm  gut.  Vaginal 
tamponing  with  iodoform  gauze,  frequently  renewed  if  necessary, 
constitutes  all  the  dressing. 

Carried  out  as  a  means  of  access,  posterior  colpotomy  presents 
no  technical  difficulty.  When  the  peritoneal  cul-de-sac  is 
opened,  we  enlarge  the  incision  with  the  finger  but  never  succeed 
in  obtaining,  according  to  Herbecourt,  a  circumference  of  more 
than  15  cm.  (6  inches). 

Results. — Immediate  results  of  posterior  colpotomy  are  excel- 
lent. The  more  distant  results  vary,  on  the  contrary,  according 
to  the  case. 

Wlien  the  collection  is  enveloped  in  a  pocket  of  recent  forma- 
tion (purulent  discharge  of  the  recto-uterine  sac,  infected 
hematocele),  the  cure  is  the  result. 

If,  on  the  contrary,  pus  is  formed  in  a  pre-existing  cavity 
(ovarian  or  tubal)  recovery  is  often  incomplete  and  after  the 
discharge  of  the  pus  there  is  an  amelioration  of  the  symptoms, 
a  fall  of  fever  and  cessation  of  pain  and  a  disappearance  of 
compression  symptoms.  But  it  is  often  a  temporary  ameliora- 
tion only  and  we  have  recourse  to  a  more  radical  operation  later. 
Even  in  these  cases  colpotomy  is  an  excellent  operation,  if  it  is 
regarded  as  simply  palliative,  so  as  to  ameliorate  their  symp- 
toms and  place  them  in  more  favorable  conditions  for  a  radical 
operation. 

Indications. — Posterior  colpotomy  is  principally  indicated  in 
acute  and  subacute  localized  infections,  if  the  examination  of  the 
patient  permits  of  determining  the  seat  of  infection.  It  is  easy  if 
there  are  large  bulging  collections  in  the  posterior  fornix.  In 
small  and  highly  situated  collections  it  is  more  difficult.  In  these 
cases  the  finding  of  a  point  of  exquisite  tenderness  is  a  great 
help  to  the  surgeon. 

Colpotomy  has  its  indications  in  certain  hematoceles,  but  we 


POSTERIOR  COLPOTOMY  217 

must  make  certain  distinctions.  In  recent  hematoceles,  in  process 
of  evolution,  when  it  is  difficult  to  say  if  the  bleeding  is  still  going 
on  or  has  recommenced,  don't  practise  this  operation.  We 
know  of  fatal  cases  of  hemorrhage  in  spite  of  tamponing  on  the 
surgeon's  part. 

In  older  hematocele,  non-suppurative,  many  gynecologists 
make  a  vaginal  incision.  Even  although  the  results  of  evacu- 
ating colpotomies  are,  in  a  general  sense,  undoubtedly  good, 
there  is  an  advantage,  we  consider,  in  having  recourse  to  the 
abdominal  route,  which  not  only  permits  of  the  evacuation  of 
blood,  but  also  of  treating  the  diseased  adnexa,  and  thus  leads 
to  less  chance  of  secondary  infection  of  the  hemic  pocket. 

On  the  contrary,  in  suppurating  hematoceles,  posterior  col- 
potomy  is  indicated. 

The  posterior  vaginal  incision  has  been  carried  out  as  pre- 
liminary operation  in  order  to  extirpate  diseased  adnexa,  of 
small  cystic  ovarian  tumors,  of  pediculated  fibroids  on  the  pos- 
terior surface  of  the  uterus,  and  in  order  to  take  out  a  fetus  in 
extrauterine  pregnancies,  etc.  We  prefer  abdominal  incision, 
however,  to  posterovaginal  celiotomy. 

It  is  said  that  exploratory  posterior  colpotomy  should  be  the 
first  stage  of  a  vaginal  hysterectomy  and  should  only  follow  the 
operation  when  the  examination  of  the  adnexa  by  the  posterior 
route  had  established  the  legitimacy  of  a  radical  intervention. 
In  practice,  it  is  often  a  bad  means  of  exploration  which  may 
mislead  greatly. 

Let  us  say  in  conclusion  that  posterior  colpotomy  may  con- 
stitute a  means  of  drainage  in  tubercular  peritonitis.  It  was  used 
by  Lohein,  but  we  do  not  approve  of  it. 

Fixing  of  the  Uterus  in  the  Vagina  with  the  Fundus  below  or 
"Bascule"  of  the  Uterus. 

Posterior  colpotomy  has  been  utilized  by  Freund  as  first  stage  of  an  opera- 
tion for  prolapse.  It  permits  of  fixing  the  uterus  in  retroflexion  in  the  vagina 
and  of  fixing  it  in  its  new  situation.  Thus  we  create  a  sort  of  large  vaginal 
tampon  which  supports  the  prolapsed  vaginal  walls. 

After  posterior  colpotomy,  Freund  "bascules"  the  uterus  on  the  vagina, 
closes  up  the  posterior  fornix,  then  after  denudation  of  the  anterior  and  pos- 
terior walls  of  the  vagina,  he  scrapes  the  uterine  surfaces  with  a  curette  and 


218 


COLPOTOMIES 


fixes  it  then  to  the  denuded  vaginal  surfaces  with  catgut  sutures.  He  con- 
cludes the  operation  by  perforating  the  fundus  of  the  uterus  projecting  into 
the  vagina. 

Shortening  of  the  Utero  -sacral  Ligament. 

After  posterior  colpotoray,  pass  a  suture  through  the  utero-sacral  liga- 
ment about  4  or  5  cm.  from  the  cervix  uteri,  and  then  pass  it  through  the 
posterior  surface  of  the  cervix  of  the  uterus.  Then  draw  the  cervix  up  and 
back,  which  will  correct  the  retro-deviation  (Gottschalk,  Stratz). 


FIG.  201. — Uterus  fixed  m  the  vagina  after  posterior  colpotomy  and  sutured  to  its 
denuded  anterior  and  posterior  walls,  and  then  perforated  at  the  fundus.  Note  the 
fundus  lies  below. 


Treatment  of  Uterine  Inversion. 

Kiistner,  after  colpotomy,  hooks  up  with  his  finger  the  tunnel  constituted 
by  the  inverted  uterus.  He  makes  a  median  vertical  incision  in  the  posterior 
surface  up  to  2  cm.  above  the  external  os  and  reduces  the  inversion  as  one 
does  the  finger  of  a  glove;  then  after  drawing  strongly  upon  the  retroflexed 
uterus  he  sutures  the  incision  made  in  the  posterior  wall. 

This  operation  has  been  modified  by  Italian  surgeons,  Piccoli,  Morisani 
and  Sava,  who  divide  the  cervix  in  its  entire  thickness  and  incise  the  uterine 
wall  in  its  whole  length.  The  uterus  is  then  formed,  as  it  were,  of  two  shells 
which  are  united  anteriorly.  Placing  the  thumbs  on  the  anterior  wall  which 
is  pushed  backward,  one  draws  forward  with  the  other  fingers  the  lips  of  the 
longitudinal  posterior  incision  and  thus  returns  the  posterior  wall.  All  that 
now  remains  is  to  suture  the  incised  posterior  wall.  Duret  advises  this 
method  of  operation  in  France. 


ANTERIOR  COLPOTOMY 

2.  Anterior  Colpotomy. 

Anterior  colpotomy,  commonly  described  in  Germany  under 
the  name  of  anterior  colpo-celiotomy,  consists  in  opening  the 
vesico-uterine  cul-de-sac  after  incision  of  the  vagina  and 
separation  of  the  bladder  and  of  the  uterus. 


FIG.  202. — Anterior  colpoceliotomy.     Track  of  the  vaginal  incision. 

Operative  Technic. — The  execution  of  anterior  colpotomy  is  a 
little  more  complex  than  posterior  colpotomy.  We  must  strip 
off  the  bladder  from  the  anterior  face  of  the  uterus  in  order  to 
reach  the  peritoneal  cul-de-sac  which  is  to  be  found  at  the  level 
of  the  isthmus  of  the  uterus.  The  operation  comprises  three 


220 


COLPOTOMIES 


principal  stages:  incision  of  the  vagina,  separation  of  the  bladder, 
and  opening  of  the  peritoneum. 

1.  Incision  of  the  Vagina. — When  anterior  colpotorny  is 
simply  done  in  order  to  evacuate  a  pre-uterine  collection,  a  trans- 
verse incision  with  a  slight  posterior  concave  curve  is  sufficient. 


FIG.  203. — Between  the  bladder  and  anterior  surface  of  the  uterus  one  may  see  the 
projection  of  the  peritoneal  cul-de-sac. 

It  passes  through  the  insertion  of  the  vagina  into  the  uterine 
cervix.  But  as  the  anterior  colpotomy  is  ordinarily  destined 
for  a  more  complex  operation  and  as  the  surgeon  must  have  as 
much  light  on  his  operation  as  possible,  it  is  more  often  the  case 
that  he  is  forced  to  combine  with  the  transverse  incision  another 


ANTERIOR  COLPOTOMY 


221 


antero-posterior  incision  4  or  ,5  cm.  long.  This  is  made  on  the 
anterior  face  of  the  vagina  so  that  we  really  have  a  T-shaped 
incision  (Fig.  202). 

The  anterior  incision  may  be  very  extensive,  so  that  some 
operators  Qonfine  themselves  entirely  to  it. 

2.  Separation  of  the  Bladder. — This  may  be  done  with  the 


FIG.  204. — Fixation  of  the  uterus  directly  to  the  vagina  without  interposition 

of  the  peritoneum. 

finger.  It  ought  to  be  done  very  thoroughly,  particularly  in  the 
transverse  direction,  and  carried  out  until  the  vesico-uterine 
cul-de-sac  is  reached  (Fig.  203). 

3.   Opening  of  the  Peritoneum. — Open  the  peritoneal  cul-de- 
sac  with  the  finger.     If  the  colpotomy  is  done  purely  for  e vacua- 


222  COLPOTOMIES 

tion,  this  method  presents  no  inconvenience,  but  if  done  as  pre- 
liminary to  a  second  operation,  the  opening  of  the  peritoneum 
should  be  carried  out  with  more  precautions.  We  should 
methodically  open  the  serous  membrane  which  appears  as  a 
floating  fold  of  grayish  color.  First  take  it  up  with  forceps  and 
then  incise  it  with  scissors  or  bistoury.  The  lips  of  the  incision 
are  immediately  taken  up  with  forceps. 

Modifications  of  Technic  According  to  Case. — 1.  Opening  of 
a  Suppurating  Focus. — When  anterior  colpotomy  is  done  with 
the  object  of  emptying  an  anteuterine  collection,  the  opening  of 
the  peritoneum  is  followed  by  the  evacuation  of  the  contents  of 
the  pocket  and  it  suffices  in  concluding  the  operation  to  place  a 
drain  in  the  site. 

2.  Means  of  Exploration. — When  the  uterus  and  adnexa  are 
fixed  by  adhesions,  the  finger  only  can  give  us  the  information 
we  require.     When  there  are  none  seize  the  uterus  with  a  pair 
of  bullet  forceps  and  drag  it  into  the  vaginal  wound ;  the  adnexa 
thus  drawn  up  may  be  examined  directly. 

3.  Removal  of  the  Adnexa  or  a  Uterine  Tumor;  Ligature  of 
the    Tubes. — The    removal    of    the    adnexa    presents    no    more 
particular    difficulty    than    manipulations    for    their    liberation. 
These  difficulties,  subordinate  to  the  extent  of  the  adhesions  and 
the  skill  of  the  operator,  may  be  great  if  the  incision  through 
which    one    works    is    limited.     The    freeing    finished,    it    only 
remains  to  extirpate  the  diseased  adnexa.     We  now  proceed  to 
the  hemostasis  following  principles  in  so  doing  which  we  will 
study  under  the  heading  of  removal  of  organs  by  the  abdominal 
route. 

Anterior  colpotomy  may  also  be  utilized  in  order  to  remove 
a  fibroma  from  the  anterior  wall  of  the  uterus  or  an  ovarian  cyst. 
It  also  permits  of  the  evacuation  of  parauterine  fetal  cyst.  By 
the  same  route  the  tubes  have  been  divided  between  two  ligatures. 

4.  Correction  of  the  Retrodeviated  Uterus  by  Vagino- fixation.— 
This  procedure  which  has  been  so  often  used  is  of  the  simplest 
character:     The    peritoneum    is    opened    and    the    uterus    and 
adnexa  are  explored.     These  are  freed  and  extirpated  if  neces- 
sary.    Then   the   uterus   is   pressed   dowrn   anteriorly   into   the 
vaginal  incision  with  the  aid  of  bullet  forceps.     It  is  seized  near 
the  fundus.     Next  a  series  of  sutures  is  passed  which  penetrates 


ANTERIOR  COLPOTOMY 


223 


FIG.  205. — The  uterus  is  strongly  drawn  down  into  the  vagina.  Passage  of  the 
suture  which  unites  the  upper  segment  of  its  anterior  surface  to  the  peritoneal  cul-de- 
sac,  which  is  well  pressed  back  before  tying  this  fixation  suture.  The  fixation  of  the 
uterus  will  be  from  this  point  sero-serous. 


224 


COLPOTOMIES 


one  of  the  lips  of  the  vaginal  wall,  traversing  the  anterior  wall 
of  the  uterus  and  coming  out  at  a  symmetrical  point  in  the  lip 
of  the  opposite  side.  We  may  use  either  silkworm  gut  or  catgut. 
The  sutures  should  not  be  tied  at  once.  Insert  them  and  then 
attach  forceps  to  them.  When  they  are  all  in  place  tie  them 
and  thus  close  the  vaginal  wound  with  which  the  pressed-down 
body  of  the  uterus  is  in  contact.  It  is  thus  fixed  in  a  posi- 
tion of  anteflexion  (Fig.  206). 

In  order  to  avoid  the  formation  of  a  cicatrix  at  the  site  of 
the  uterine  fixation  and  in  order  to  obtain  simply  a  sero-serous 


FIG.  206. — Uterus  with  fundus  below  at- 
taches in  the  vagina  after  anterior  col- 
potomy  and  fixed  to  a  denuded  portion  of 
the  vesico- vaginal  septum. 


FIG.  207. — Uterus  with  fundus  below 
fixed  in  the  thickness  of  the  vesico- va- 
ginal septum. 


fixation  Duhrssen  modifies  the  operation  in  the  following  way: 
He  does  an  ordinary  colpotomy,  inserts  a  single  fixation  suture 
consisting  of  a  large  silkworm-gut  suture.  This  traverses  one 
of  the  lips  of  the  vertical  segment  of  the  vaginal  incision  near  its 
upper  extremity,  traverses  the  vaginal  wall,  then  the  corre- 
sponding lip  of  the  peritoneal  incision,  includes  the  anterior  wall 
of  the  uterus  and  comes  out  through  the  peritoneal  and  vaginal 
lips  of  the  opposite  side  thus  following  a  symmetrical  course 
(Fig.  203).  A  pair  of  forceps  seizes  the  two  extremities  of  the 
fixation  suture,  which  is  tied  at  the  end  of  the  operation. 


ANTERIOR  COLPOTOMY 


225 


We  then  proceed  to  the  closing  of  the  peritoneal  cul-de-sac 
by  a  sagittal  continuous  suture  and  then  the  vaginal  incision  is 
closed.  The  peritoneal  suture  and  the  vaginal  suture  ought  to  be 
absolutely  independent,  one  of  the  other.  Nothing  more  re- 
mains to  conclude  the  operation  than  to  tighten  and  tie  the  fixa- 
tion suture. 


FIG.  208. — The  uterus  is  drawn  into 
the  wound  of  the  colpo-celiotomy.  The 
tubes  are  tied  and  then  cut  across  to 
secure  sterilization  of  the  patient. 


FIG.  209. — The  uterus  in  "bas- 
cule" (that  is  the  fundus  is  drawn 
down  and  the  organs  thus  in- 
verted) in  the  vagina.  The  ab- 
dominal cavity  is  closed  by  sutur- 
ing the  retro-vesical  peritoneum 
to  the  posterior  surface  of  the 
uterus,  which  has  become  ante- 
rior owing  to  the  inversion  of  the 
organ. 


As  dressing  use  a  tampon  of  iodoform  gauze.  If,  like  Duhrs- 
sen,  silkworm  guts  are  used  to  suture  the  vagina  and  fix  the 
uterus,  they  are  removed  on  the  tenth  day. 

After  the  operation  the  anterior  surface  of  the  uterus  is  applied 
to  the  serous  covering  of  the  new  peritoneal  cul-de-sac.  It  is 
then  maintained  in  its  new  position  by  pure  peritoneal  adhesions 

15 


226 


COLPOTOMIES 


and  there  is  no  fibrous  nodule  in  the  cellular  pre-uterine  tissue. 
By  this  procedure  the  uterus  is  anteflexed  and  without  fixingTit 
tightly  to  the  vaginal  wall  it  is  allowed  a  certain  amount  of 
mobility.  Vagino-fixation  was  advocated  in  France  by  Le  Dentu 
and  Pichevin. 

5.  Fixing  of  the  Uterus  in  the  Vagina  with  the  Fundus  below  or 
the  "inversion"  of  the  Uterus. — For  the  "inversion"  of  the  uterus 


FIG.  210. — The  uterus  is  placed  in  contact 
with  the  bladder.  The  suture  of  the  vaginal 
flaps  is  commenced  posteriorly. 


FIG.  211. — The  suture  of  the  va- 
ginal wall  is  concluded,  having 
exposed  a  slight  extent  of  uterine 
tissue. 


in  the  vagina  after  Freund's  posterior  colpotomy,  Fortsch  substi- 
tuted, in  the  treatment  of  prolapse,  the  "inversion"  by  an  incision 
made  in  front  of  the  cervix.1 

The  uterus  is  fixed  to  the  anterior  wall  of  the  vagina,  from 
which  an  oval  has  been  excised ;  posteriorly  it  is  lodged  n  a  sort 
of  bed  formed  of  two  little  flaps  cut  from  the  right  andleft  of  a 
T-shaped  incision  in  the  posterior  vaginal  wall. 


1  Fritsch,  Cent.  Bl.  fur  Gyn.,  1900,  No.  2.  Wertheim  is  content  with  fixation  to 
anterior  wall  of  vagina  (Ibid.,  1899,  No.  14)  and  Buruka  (Zeitsch.  fur  Geb.  und  Gyn., 
1901,  T.  XLV,  p.  422). 


ANTERIOR  COLPOTOMY  227 

This  operation  has  the  inconvenience  of  suppressing  com- 
pletely the  vaginal  cavity.  It  was  soon  abandoned  for  the 
fixation  of  the  uterus  in  the  substance  of  the  vesico-vaginal 
septum,  thus  preserving  a  vagina  useful  for  copulation  (Watkins,1 
Wertheim,  Schauta,  see  Fig.  207) . 

The  operation  is  done  in  the  following  manner:  A  sagittal 
incision  in  the  median  line  on  the  anterior  surface  of  the  vagina, 
going  as  far  as  the  posterior  part  of  the  urethral  meatus.  Separa- 
tion of  the  flaps  from  each  side  of  this  incision.  Posteriorly, 
in  contact  with  the  bladder,  make  a  transverse  incision  which 
leads  into  the  retro-vesical  space,  which  is  separated.  Open  the 
vesico-uterine  cul-de-sac  and  tilt  the  uterus  anteriorly.  If  the 
woman  is  in  the  period  of  sexual  activity,  in  order  to  avoid  con- 
ception ligature  and  cut  through  the  tubes  (Fig.  208).  Then 
draw  the  uterus  into  the  anteflexed  position  and  close  the  perit- 
oneal cavity  above  it  by  suturing  the  retro-vesical  peritoneum 
to  that  of  the  posterior  wall  of  the  cervix  (Fig.  209) .  The  uterus 
is  then  lodged  in  the  niche  created  by  the  incision  and  separation 
of  the  vagina,  its  posterior  wall  being  in  contact  with  the  bladder 
and  its  sides  with  the  dihedral  angles  resulting  from  the  separa- 
tion of  the  incision. 

The  vaginal  flaps  are  sutured  above  the  uterus  of  which 
a  small  portion  remains  exposed  in  the  vagina  (Figs.  210  and  211). 
This  is  of  no  importance,  as  the  uterine  surface  becomes  covered 
with  epidermis  during  the  weeks  following  the  operation.2 

This  operation  is  not  always  possible. 

If  the  uterus  is  too  big  to  lodge  in  the  space  created  by  the 
separation  of  the  vaginal  flaps,  we  do  a  hysterectomy.  This 
is  done  by  Landau.  Once  the  uterus  is  "inverted "  in  the  vagina, 
he  closes  the  peritoneum  with  silkworm-gut  sutures,  which 
unite  the  peritoneum  of  the  pouch  of  Douglas  with  the  superior 
angle  of  the  vaginal  incision  and  the  vesical  peritoneum  and 
which  takes  up  some  uterine  tissue  en  passage,  so  that  the  pos- 
terior wall  of  the  cervix  is  fixed  in  an  elevated  position.  Liga- 

1  Watkins,  Amer.  Gyn.  and  Obslet.J.,  Nov.,  1899 ;  Surg,,  Gyn.  and  Obstet.,  June,  1896, 
p.  659. 

2  Hastings  Tweedy  combines  an  analogous  operation  by  suture  of  the  two  broad  liga- 
ments in  front  of  the  isthmus,  which  carry  the  cervix  up  and  back.     For  that,  after  in- 
verting the  uterus  into  the  vagina,  he  unites  the  base  of  the  broad  ligaments  near  their 
pelvic  extremity  with  strong  silk  and  ties  them  together.     (E.  Hastings  Tweedy,  Cura- 
tive Operation  for  Procidentia  Uteri.    Journ.  of  Obstet.  and  Gynec.  of  the  British  Empire, 
London,  1905,  T.  I,  p.  349.) 


228 


COLPOTOMIES 


tures  inserted  into  the  lateral  tissues  of  the  uterus  or,  if 
possible,  outside  the  adnexa,  suffice  to  secure  hemostasis.  Lift 
out  the  uterus  and  fix  the  pedicles  to  the  corresponding  part  of 
the  vaginal  flaps. 


FIG.  2  1  2  .— Retroflexed 
uterus.  Passage  of  a  suture 
through  its  anterior  face. 


FIG.  213.— The  loop 
of  the  suture  is  tight- 
ened without  the  ex- 
tremities being  tied. 
The  uterus  is  re- 
dressed. 


6.  Redressing  the  Retrodeviated  Uterus  by  Uteroplasty. — Doyen,  relying  on 
the  fact  that  in  permanent  flexion  of  the  uterus  the  convex  wall  of  the  organ 
distends  considerably  in  its  length,  proposes  to  unite  by  a  suture  two  points 


FIG.  214. — Passage  of  sutures  seen  from  front. 


of  the  anterior  wall  of  the  uterus  passing  exclusively  through  the  superficial 
strata  of  the  muscle  in  order  to  obtain  immediate  correction  of  the  organ 
(Figs.  212  and  213). 


ANTERIOR  COLPOTOMY  229 

Anterior  colpo-celiotomy,  as  clone  by  Doyen,  consists  in  passing  a  loop  of 
sutures  3  mm.  deep  and  15  mm.  broad  into  the  substance  of  the  uterus  and 
then  the  needle  is  passed  through  the  superficial  layers  of  the  supravaginal 
portion  of  the  cervix.  The  extremities  of  the  suture  are  now  tied  and  thus 
shorten  the  anterior  wall  of  the  uterus  (Fig.  214). 

A  reinforcing  suture,  inserted  above  the  first,  assures  the  success  of  the 
operation. 

Elischer  resects  from  the  uterus  which  has  been  drawn  into  the  vaginal 
wound,  a  U-shaped  flap.  He  denudes  the  anterior  surface  of  the  cervix  and 
then  brings  the  flap  and  denuded  surface  into  apposition  and  fixes  them. 

7.  Shortening  of  the  Uterine  Ligaments. — After  anterior  colpotomy  is 
done: 

a.  Shortening  of  the  round  ligaments  temporarily  drawn  into  the  vaginal 


FIG.  215. — Incision  of  the  anterior  fornix  and  anterior  wall  of  the  uterus  (Oui). 

wound  (Bode,  Godinho),  combining  sometimes  this  shortening  with  vaginal 
fixation  of  the  ligaments  (Wertheim,  Vineberg,  Hall). 

b.  Shortening  of  the  large  ligaments  sutured  one  to  the  other  in  front  of 
the  uterus  (Kochs). 

8.  Reduction  of  Uterine  Inversion. — Spinelli,  after  anterior  colpotomy, 
makes  an  analogous  operation  to  that  which  Piccoli  advocated  by  the  posterior 
route.  On  the  index  introduced  into  the  funnel  formed  by  the  inverted 
uterus,  he  incises  the  cervix  vertically  and  the  anterior  wall  of  the  uterus  up 
to  the  f undus  of  that  organ.  After  reduction,  he  sutures  the  uterine  incision 
and  concludes  with  a  vagino-fixation  according  to  Diihrssen's  method. 

In  France,  Oui  operated  in  the  following  manner:  After  drawing  the 
uterus  out  of  the  vulva,  he  makes  just  above  the  external  os,  which  is  easily 
recognized  by  sight  (change  in  coloration)  and  by  palpation  (difference  in 
thickness)  a  semicircular  incision  which  opens  the  anterior  fornix  freely. 


230 


COLPOTOMIES 


This  incision  should  be  very  extensive  so  as  to  enable  the  operator  to  easily 
return  the  uterus  back  through  it  into  the  abdominal  cavity. 

Anterior  colpo-celiotomy  having  been  done,  the  infundibulum  of  the 
inversion  is  examined  by  digital  exploration  in  order  to  be  quite  sure  it 
contains  no  other  organ  (bladder,  intestine)  which  might  be  injured  by  the 
incision. 

With  scissors  or  a  blunt  bistoury,  guided  by  the  finger,  the  anterior  wall  of 
the  uterus  is  incised  in  the  median  line  in  all  its  thickness  from  external  os  to 
fundus  (Fig.  215). 

Now  the  reduction  stage  arrives.  The  thumbs  are  applied  to  the  poste- 
rior wall  of  the  uterus;  the  index-fingers  seize  the  lips  of  the  uterine  incision 
and  draw  them  out  and  in  so  doing  unfold  the  uterus  (Fig.  216).  In  con- 
tinuing this  movement  we  gradually  complete  the  rein  version  of  the  organ. 
The  fundus  of  the  uterus  is  then  directed  down  and  forward,  the  cervix 
assuming  a  position  pointing  up  and  back. 


FIG.  216. — Reinversion  of  the  uterus  (Oui). 

The  uterus  having  been  reduced,  the  wound  is  united  from  fundus  to 
isthmus  by  an  interrupted  catgut  suture.  The  sutures  are  about  1  cm.  apart 
and  take  up  the  entire  thickness  of  the  uterine  wall  with  the  exception  of  its 
mucous  membrane.  Between  these  sutures  other  catguts  are  placed,  taking 
up  the  serous  coat  and  the  superficial  layers  of  the  muscular  in  such  a  man- 
ner as  to  get  accurate  apposition  of  the  peritoneum. 

The  fundus  of  the  uterus  is  then  pushed  up  and  back  and  returned  through 
the  vaginal  incision  into  the  abdomen. 

The  cervix  is  sutured  with  catgut  as  also  the  vaginal  fornix. 

Results. — Immediate  results  of  anterior  colpotomy  are  fairly 
good.  Duhrssen  in  503  cases  had  fifteen  deaths;  Martin  had 
only  four  in  471  cases.  The  bladder  is  less  often  injured  than 
one  would  think  a  priori.  Martin  has  had  this  occur,  however, 
in  five  of  his  interventions. 


ANTERIOR  COLPOTOMY 


231 


FIG.  217. — Suture  of  the  reinverted  uterus  (Oui). 


FIG.  218. The  uterus  has  been  replaced  by  the  vaginal  incision.     There  remains  now 

only  the  suture  of  the  uterine  cervix  and  of  the  anterior  fornix. 


FIG.  219. — Operation  terminated  (Oui). 


232 


COLPOTOMIES 


In  short,  in  simple  cases  where  the  adnexa  are  healthy  or 
little  diseased  and  the  essential  operation  consists  in  the  fixation 
of  the  uterus,  the  gravity  is  very  restricted.  What  are  the 
remote  results  ?  Retrodeviation  may  occur.  The  proportion  of 
these  recurrences  varies  according  to  the  procedure  employed. 
To-day  they  seem  particularly  frequent  with  the  procedures 
in  which  only  the  inferior  part  of  the  uterus  is  fixed. 

From  the  obstetrical  point  of  view,  remote  results  are  of 
no  particular  interest. 

Complications  are  due  to  uterine  fixation.  These  compli- 
cations are  of  two  other  orders:1  Abortion  or  premature  labor: 
25  to  27  per  cent,  according  to  Strassmann.  Also  dystocia 
due  to  the  uterus  developing  unequally  during  labor.  The 
body  of  the  uterus  develops  almost  exclusively  at  the  expense 
of  the  postero-superior  wall  which  causes  the  os  to  look  up 


FIG.  220.  FIG.  221. 

Deformities  of  the  pregnant  uterus  after  vaginal  fixation  ( Klein wachter). 

toward  the  promontory  (Fig.  220).  When  the  head  enters  the 
true  pelvis,  it  only  does  so  by  distending  that  part  of  the 
anterior  face  situated  between  the  cervix  and  the  fixed  point 
of  the  uterus  (Fig.  221). 

We  find  therefore  a  head  engaged  but  covered  over  by  the 
anterior  wall  of  the  uterus;  the  cervix  is  very  high,  sometimes 
above  the  promontory.  The  axis  of  the  child  may  be  in  these 
conditions  more  or  less  perpendicular  to  the  axis  of  the  pelvis. 
Ordinarily  the  uterus,  as  a  result  of  the  pressure  of  the  anterior 

1  Oui,  Hysteropexy  from  the  Point  of  View  of  its  Influence  on  Pregnancy.     Ann. 
de  gyn.,  Paris,  1904,  p.  225. 


ANTERIOR  COLPOTOMY  233 

abdominal  wall  of  the  uterus,  deviates  and  a  transverse  presen- 
tation is  produced.  According  to  Kleinwachter  this  occurs  in 
15.67  per  100  cases. 

The  complications  in  different  labors  have  also  another 
cause.  The  union  of  the  anterior  wall  of  the  uterus  and  of 
the  corresponding  wall  of  the  vagina  produces  at  the  point  of 
union  a  fibrous  cicatricial  area,  upon  which  the  development  of 
pregnancy  has  no  influence.  Also  it  is  common  to  observe  that 
during  a  pain  there  is  a  rigidity  of  the  anterior  half  of  the  cervix. 
If  this  is  borne  in  mind  and  also  the  part  that  the  postero-superior 
wall  of  the  uterus  plays  during  labor,  in  short,  practically  the4 
entire  role  becoming  very  thinned,  one  can  easily  understand 
ruptures  occurring  at  this  level. 

Since  then  defenders  of  vagino-fixation  have  endeavored  to 
avoid  dystocic  complications. 

From  this  Duhrssen's  procedure  takes  its  origin.  We  have 
already  described  it  and  his  method  endeavors  to  replace  the 
fibrous  cicatrix  by  simple  peritoneal  adhesions,  susceptible  under 
the  influence  of  pregnancy  to  undergo  the  important  anatomical 
modifications  which  lead  to  increased  size  of  the  uterus. 

Indications.— In  short,  with  the  exception  of  the  abstraction 
of  pre-uterine  suppurative  collections  where  anterior  colpotomy 
may  be  employed  as  the  operation  of  necessity,  wrhat  other  cases 
present  themselves  for  its  use  ?  In  a  general  sense  when  it  is  a 
question  of  the  extirpation  of  uterine  tumors,  such  as  fibroma 
of  the  anterior  wall,  or  para-uterine  tumors,  such  as  ovarian 
cysts,  it  appears  to  us  as  an  operation  which  is  inferior  to  that 
of  the  abdominal  route.  It  is  even  firmly  contraindicated  in 
adherent  tumors  and  malignant  tumors  or  solid  tumors  larger 
than  the  closed  fist. 

In  retrodeviations  complicated  by  extensive  adhesions  with 
neighboring  organs,  anterior  colpotomy,  wrhich  gives  a  limited 
operative  field,  should  be  rejected  and  we  would,  without  hesi- 
tation, choose  the  abdominal  route.  But,  in  simple  cases  of 
adherent  or  slightly  adherent  retroflexion,  with  healthy  or  slightly 
diseased  adnexa,  anterior  colpotomy  may  give  good  results.  It 
has  the  advantage,  if  it  is  combined  simultaneously  with  a 
curettage  or  colporrhaphy,  of  fulfilling  the  different  indications 
by  purely  vaginal  intervention.  In  such  a  way  one  avoids  the 


234  COLPOTOMIES 

loss  of  time  which  must  occur  as  a  result  of  the  changes  of 
position  of  the  patient. 

Personally,  we  prefer  in  these  cases  the  abdominal  operation. 
If,  at  the  same  time,  it  is  decided  to  try  a  vagino-fixation,  what 
proceeding  should  one  employ  ?  All  depends  on  the  age  of  the 
patient.  If  she  has  reached  the  menopause,  if  she  has  under- 
gone a  bilateral  extirpation  of  the  adnexa,  we  may  have  recourse 
to  a  direct  and  extensive  vagino-fixation.  If  it  is  a  young 
woman,  capable  of  pregnancy,  we  advise  Duhrssen's  operation. 
This  operation  does  not  put  all  recurrence  out  of  the  question, 
especially  if  pregnancy  occurs.  But  the  possibility  of  a  recur- 
rence, otherwise  problematic,  is  nothing  compared  to  the  cer- 
tainty one  has  of  avoiding  the  redoubtable  dystocial  complica- 
tions imparted  to  the  primitive  procedure. 

In  prolapse,  the  operation  of  Wertheim-Schauta  which  con- 
sists in  fixation  of  the  inverted  uterus  in  anteflexion  and  the 
forcing  of  it  into  the  substance  of  the  vesico-vaginal  septum,  it 
counts  a  certain  number  of  partisans  in  Germany.  The  same 
operation  has  given  us,  as  also  Hofmeier,  good  results  in  re- 
bellious cases  of  incontinence  of  urine. 


CHAPTER  VIII. 

VAGINAL  HYSTERECTOMY. 

Summary. — Technic  (pre-operative  precautions,  operation,  postopera- 
tive precautions). — Operative  difficulties. — Complications. — Various  pro- 
cedures (Doyen,  Pean,  Segond,  Miiller,  Que"nu,  J.  L.  Faure). — Operative 
modifications  according  to  the  lesion  (cancer,  fibromata,  inflamed  adnexa, 
puerperal  infection,  prolapse,  uterine  inversion,  juxta-uterine  tumors). 

The  first  surgeon  to  excise  the  uterus  with  success  by  the 
vaginal  method  was  Sauter  of  Constance  (1822).  He  operated 
without  forceps  or  ligatures  and  yet  his  patient  was  cured.  In 
1829  Recamier  did  the  same  operation,  but  ligatured  the  uterine 
arteries.  Unfortunately  the  high  mortality  made  the  operation 
fall  into  oblivion,  from  which  it  was  restored  to  the  light  by 
Czerny,  who  on  the  twelfth  of  August,  1878,  did  a  vaginal 
hysterectomy  for  cancer  of  the  cervix.  At  first,  vaginal  hyster- 
ectomy was  reserved  for  this  affection.  Its  indication,  however, 
soon  became  more  extended. 

Thanks  to  Pean  firstly,  to  Segond,  Richelot  and  latterly  to 
Doyen,  vaginal  hysterectomy  was  applied  in  a  systematic  fashion 
to  treatment  of  the  adnexa,  and  then  to  fibromata. 

Its  operative  technic  has  been  considerably  simplified  owing 
to  the  introduction  of  forcipressure  and  to  morcellement. 

Among  numerous  operative  procedures  which  were  succes- 
sively utilized,  we  should  give  a  place  apart  to  that  of  Doyen  to 
whom  is  due  the  merit  of  introducing  a  technic  so  simple  and  so 
rapid  as  to  vulgarize  vaginal  hysterectomy. 

In  spite  of  the  operative  perfection  and  the  excellence  of  the 
results,  vaginal  hysterectomy,  having  had  a  very  considerable 
vogue  in  the  treatment  of  inflammation  of  the  adnexa,  fibro- 
mata and  cancer,  has  lost  much  ground  and  tends  more  and 
more  to  be  replaced  by  abdominal  hysterectomy. 

235 


236 


VAGINAL   HYSTERECTOMY 


1.  Operative  Technic. 

Preparatory  Precautions. — Vaginal  hysterectomy  renders  cer- 
tain pre-operative  precautions  necessary  which  it  is  important 
not  to  neglect.  Several  days  before  the  operation  the  patient 


FIG.  222.— Short  vaginal 
speculum. 


FIG.  223. — Long  and  narrow  speculum. 


will  take  large  vaginal  injections  twrice  daily.     Give  a  purge 
the  night  before  the  intervention. 

Before  operating  look  to  the  toilet  of  the  vagina  and  vulva. 
This  is  a  lengthy  and  minute  operation.     The  vulva  should  be 


FIG.  224. — Museux's  heavy  forceps. 

completely  shaved;  wrash  with  soap  not  only  the  external  parts 

but  also  the  vagina  itself. 

The  following  is  a  list  of  instruments  required : 

Several   vaginal   specula,    one   about   5   or   6   cm.    long,   to 


OPERATIVE  TECHNIC  237 

press  down  the  fourchette,  two  ordinary  vaginal  specula,  two 
long  and  narrow  specula  about  35  mm.  long  in  order  to  protect 
the  bladder,  some  tampon  holders,  six  pairs  of  Museux's  strong 
forceps  to  draw  the  uterus  down,  one  hysterometer,  one  bistoury, 
some  straight  and  curved  scissors,  pressure  forceps,  one  pair 
of  tenaculum  forceps,  some  Kocher's  forceps,  two  ring  forceps 
to  draw  on  the  adnexa  and  eight  pairs  of  short  and  powerful 
pressure  forceps. 

The  relative  position  of  the  operator  and  his  assistants  is 
the  same  as  for  all  vaginal  operations. 

Two  assistants  are  indispensable;  one  is  placed  to  the  right 
and  the  other  to  the  left. 

'The  instruments  are  to  the  right  of  the  operator. 

In  order  to  avoid  any  sepsis  the  operative  field  should  be 
extensive.  It  is  important  to  fix  the  posterior  compress  so  as 
to  conceal  the  anus.  Three  little  tenaculum  forceps  are  dis- 


FIG.  225. — Short  and  strong  artery  forceps. 

posed  so  that  one  is  on  a  line  with  the  fourchette,  and  two 
others  over  the  buttock;  fix  this  compress  and  in  order  to  be 
quite  sure  of  the  fixation  allow  them  to  take  up  at  the  same 
time  a  little  fold  of  the  subjacent  tissues. 

The  bladder  is  emptied  with  a  catheter. 

Operation. — The  operation  should  then  commence. 

The  fourchette  being  pressed  down  by  the  short  speculum, 
the  cervix  is  seized  with  two  pairs  of  traction  forceps  inserted 
into  the  anterior  lip  near  the  commissures.  The  hold  should 
be  firm;  the  uterus,  by  slow  and  progressive  traction,  is  drawn 
down  to  the  vulva  (Fig.  226).  Holding  the  two  forceps  in  the 
left  hand  the  operator,  with  scissors  or  a  knife,  held  in  the  right 
hand,  makes  a  circular  incision  of  the  cervix.  The  majority  of 
surgeons  make  a  circular  incision.  We  believe  with  Segond, 


238 


VAGINAL   HYSTERECTOMY 


that  it  is  of  benefit  to  add  to  this  circular  incision  two  small 
lateral  ones. 

If  the  knife  is  used,  the  incision  is  performed  in  the  following 
manner:  Two  little  retractors  are  placed  in  the  lateral  fornices. 
The  assistant  to  the  right  of  the  patient  commences  by  strongly 


FIG.  226. — The  uterus  is  drawn  down  with  two  of  Museux's  heavy  forceps;  the  vaginal 
walls  are  drawn  back  with  retractors. 

pressing  down  with  his  retractor  the  corresponding  vaginal  wrall 
while  the  surgeon  with  his  left  hand  draws  the  cervix  strongly 
toward  the  left.  The  fornix  is  thus  well  exposed  and  stretched. 
Taking  the  bistoury,  the  operator  commences  the  incision  in 


OPERATIVE   TECHNIC 


239 


this  fornix  about  4  cm.  from  the  right  commissure.  This  incision 
is  directed  at  first  transversely  toward  this  commissure  but  when 
the  bistoury  is  about  11/2  cm.  from  it  the  instrument  is  directed 
forward  and  cuts  through  the  anterior  fornix  on  the  cervix.  Dur- 
ing this  procedure  the  cervix  is  drawn  toward  the  right.  The 
left  retractor  now  plays  its  role  in  that  it  permits  of  the  knife 


FIG.  227. — Circular  incision  of  the  cervix  with  lateral  incisions. 

in  making  a  short  lateral  incision  in  the  left  fornix  symmetrical 
with  that  on  the  opposite  side. 

In  inserting  a  posterior  speculum  and  in  drawing  the  cervix 
forward,  one  is  enabled  to  circumscribe  the  cervix  by   tracing 


240 


VAGINAL   HYSTERECTOMY 


a  curved  incision  posteriorly,  and  then  proceeding  toward  the 
front  about  1  1/2  cm.  from  the  external  os1  (Fig.  228). 


FIG.  228. — Posterior  part  of  the  circular  incision  of  the  cervix. 

The  danger  is  the  bladder;  by  keeping  about  15  to  18  mm. 
from  the  cervix  there  is  nothing  to  fear.     In  case  of  doubt  regard- 

1  Some  operators  prefer  to  attack  the  vagina  with  strong  curved  scissors.  The 
cervix  should  be  assailed  on  its  posterior  right  face.  The  left  hand  drawing  on  the 
forceps  pulls  it  forward  and  the  scissors  cut  into  the  right  of  the  cervix  (to  left  of  the 
operator)  about  2  cm.  from  the  external  os  and  with  some  few  cuts  sever  the  posterior 
vaginal  portion;  often  the  pouch  of  Douglas  is  opened  in  this  manipulation,  but  it 
is  of  no  importance.  When  the  scissors  is  on  the  left  side  of  the  cervix,  the  left  hand 
manipulates  in  such  a  way  as  to  expose  clearly  the  lateral  surface,  then  the  anterior  surface 
of  the  cervix  and  the  scissors  circumscribe  the  cervix  by  cutting  through  the  insertion 
of  the  vagina;  their  extremity,  applied  to  the  uterus,  severs  gradually  the  anterior 
insertion  of  the  vagina  and  then  goes  to  the  left  of  the  operator  to  unite  with  the  first 
incision  at  its  starting  point.  The  disinsertion  of  the  vagina  is  finished  (J.  L.  Faure). 


OPERATIVE   TECHNIC 


241 


ing  its  limits  there  is  nothing  simpler  than  to  introduce  a  sound  so 
as  to  accurately  determine  its  limits. 

The  cervix  thus  circumscribed  should  be  freed.  Commence 
by  opening  the  posterior  fornix.  To  do  this,  the  cervix  being 
carried  forward,  the  index-finger  is  forced  between  the  lips  of  the 
posterior  part  of  the  vaginal  incision  and  endeavors  to  burst 
through  the  peritoneal  cul-de-sac.  If  this  is  free,  the  action  is  easy 


FIG.  229. — Separation  of  the  bladder. 

and  the  finger  soon  feels  as  if  it  were  in  a  cavity,  where  it  feels 
intestinal  loops  or  even  prolapsed  adnexa. 

If  the  cul-de-sac  is    full  of  adhesions  the  peritoneal  cavity  is 
difficult  to  find.     It  is  in  these  cases  that  wre  must  proceed  me- 


Ki 


242 


VAGINAL   HYSTERECTOMY 


thodically.  The  index-finger  ought  not  to  lose  the  contact  of  the 
posterior  surface  of  the  uterus,  which  is  the  best  of  landmarks. 
It  feels  its  way  along  the  length  of  this  surface  until  it  reaches 
the  level  of  the  fundus.  In  complex  cases  it  happens  some- 
times that  in  this  little  manipulation  one  or  more  suppurative 
foci  are  opened. 


FIG.  230. — Median  anterior  hemisection  of  the  uterus. 

The  uterus  is  freed  behind  and  no\v  it  must  be  freed  ante- 
riorly. To  do  so,  carry  the  cervix  down  and  back  toward  the 
fourchette,  separate  the  bladder  with  the  right  index-finger  (Fig. 
229)  or  with  blunt  curved  scissors  which  may  be  used  to  press 


OPERATIVE  TECHNIC  243 

back  the  tissues  and  also  to  cut  through  the  parts  which  resist 
the  separation. 

Above  all,  at  the  level  of  the  median  line  adhesions  are  most 
marked,  as  we  have  already  had  occasion  to  observe  when  describ- 
ing anterior  cplpotomy. 

The  separation  of  the  bladder  should  be  very  complete.  It 
is  carried  out  as  extensively  as  possible  laterally  in  order  to 
separate  the  ureters  from  the  operative  field. 

In  the  course  of  these  manipulations  the  vesico-uterine  cul- 
de-sac  is  often  opened.  If  it  is  not,  it  may  be  recognized  by  its 
white  color,  which  differentiates  from  the  neighboring  cellular 
tissue  and  may  be  opened  by  a  single  cut  of  the  scissors. 

When  the  uterus  does  not  descend  well  and  the  peritoneal 
cul-de-sac  is  not  to  be  seen,  we  should  proceed  without  waiting  to 
the  next  stage:  Anterior  hemisection  of  the  uterus  or  median  section 
of  the  anterior  wall  as  recommended  by  Doyen  (Fig.  230). 

This  hemisection  is  done  in  the  following  manner.  Two 
traction  forceps  are  placed  at  the  level  of  each  of  the  commissures 
of  the  cervix.  The  posterior  limb  of  a  pair  of  straight  blunt 
scissors  is  introduced  into  the  cervical  cavity  and  the  anterior 
wall  is  cut  through  as  far  as  the  isthmus,  or  even  a  little  higher, 
remembering  always  to  follow  exactly  the  anterior  median  line. 
This  cut  does  not  bleed.  On  each  lip  of  the  incision,  as  high  as 
possible,  place  a  pair  of  traction  forceps. 

By  drawing  on  these  forceps,  which  hold  the  uterus  very 
firmly,  its  anterior  face  is  sensibly  depressed  and  at  the  same  time 
a  slight  anterior  flexion  is  imparted  to  the  organ. 

A  new  part  of  the  uterus,  not  incised,  now  appears.  Taking 
the  scissors  again,  the  surgeon  cuts  through  all  the  visible  portion 
of  the  accessible  anterior  face.  A  third  pair  of  traction  forceps  is 
placed  on  one  of  the  lips  of  the  incision  above  the  first  pair  (Fig. 
231).  This  pair  may  then  be  taken  off  and  reattached  on  the 
most  elevated  portion  of  the  opposite  lip  of  the  same  incision. 

One  ascends  thus  toward  the  fundus  of  the  uterus,  in  a  sense 
making  the  traction  forceps  climb  the  anterior  median  incision 
which  the  operator  continues  to  prolong.  This  progressive  ascen- 
sion of  traction  forceps  brings  about  a  more  and  more  marked 
tilting  of  the  body  of  the  uterus.  In  the  meantime  the  vesico- 
uterine  cul-de-sac  has  been  opened; a  long  and  narrow  speculum 


244 


VAGINAL    HYSTERECTOMY 


is  introduced  into  its  cavity,  protecting  the  bladder  and  pressing 
back  the  loops  of  intestine  which  tend  to  descend.  When  the 
median  anterior  incision  approaches  the  fundus  of  the  organ  and 
the  traction  forceps  are  inserted  very  close  to  this  point,  tilt- 
ing of  the  uterus  occurs  and  the  body  is  turned  completely  inside 
out  into  the  vagina  (Fig.  232) . 


FIG.  231. — Progressive  ascension  of  the  forceps  as  the  hemisection  proceeds. 

We  must  now  free  the  adnexa.  Commence  with  those  on  the 
left  side.  The  index- finger  and  medius  of  the  left  hand  are  intro- 
duced above  the  fundus  of  the  uterus  and  are  directed  toward  the 
posterior  aspect  of  the  broad  ligament  and  then  they  commence 


OPERATIVE  TECHXIC 


245 


to  slowly  detach  the  adherent  adnexa.  This  freeing,  which  is 
easy  in  some  cases,  may  be  very  difficult,  even  impossible.  We 
will  have  to  return  to  this  point  and  the  line  qf  action  to  take  in 
these  cases  when  we  study  the  application  of  vaginal  hysterectomy 
with  reference-to  the  adnexa,  and  we  will  not  dwell  for  the  moment 


FIG.  232. — The  incision  has  reached  the  fundus  of  the  organ.     The  body  of  the  uterus 

is  tilted  forward. 

on  this  separation.  Having  freed  the  adnexa,  these  are  directed 
toward  the  uterus  and  hemostasis  of  the  broad  ligament  is  carried 
out.  In  order  to  do  this,  charge  the  assistant  to  the  right  with  the 
care  of  the  uterus,  and  request  him  to  gently  draw  it  to  his  side. 
Then  place  the  clamps  in  position  under  the  double  control  of 


246 


VAGINAL   HYSTERECTOMY 


eye  and  finger.  In  no  case  place  forceps  on  a  broad  ligament  un- 
less under  control  of  the  eye.  A  short  and  strong  pair  of  artery 
forceps,  the  modeUof  which  we  have  indicated,  is  attached  from 
below  up,  external  to  the  cervix;  it  is  made  to  seize  the  interior 
half  of  the  broad  ligament  where  the  uterine  pedicle  is  situated. 


FIG.  233. — Freeing  of  left  adnexa. 


At  the  same  time  the  two  fingers  of  the  left  hand,  introduced  into 
the  recto-uterine  cul-de-sac,  keep  away  the  intestinal  loops.  A 
similar  pair  of  forceps  is  attached  in  the  inverse  sense,  that  is, 
from  above  downward,  to  the  upper  part  of  the  broad  ligament, 
external  to  the  adnexa  and  securing  the  superior  pedicle.  The 


OPERATIVE   TECHNIC 


247 


two  forceps  should  he  so  placed  that  between  them  no  part  of  the 
broad  ligament  should  be  exempt  from  pressure  (Fig.  234) .  With 
scissors  we  cut  through  the  broad  ligament  about  1  cm.  external 
to  the  clamps. 

Then  we. go  on  to  the  freeing  of  the  right  adnexa.     Having 


FIG.  234. — Forceps  placed  on  the  left  broad  ligament. 


done  this,  the  termination  of  the  operation  is  very  simple.  The 
uterus  which  is  only  attached  by  the  broad  ligament  of  the  right 
side  should  be  guided  to  the  vulva  and,  as  on  the  left  side,  two 
pairs  of  forceps  should  be  placed,  one  from  below  up  and  the 


IMS 


V  A  < :  I XAL    H YS1 ERECTOM  Y 


other  from  above  down  (Fig.  235).     A  cut  of  the  scissors  internal 
to  these  forceps  enables  us  to  make  the  final  separation. 

The  two  upper  forceps,  placed  on  the  utero-ovarian  pedicle, 
fall  in  front  of  the  two  forceps  placed  on  the  uterine  pedicle;  in 
this  movement  they  drag  with  them  the  upper  portion  of  the  broad 


FIG.  235. — Forceps  on  the  right  broad  ligament. 


ligaments  and  bring  about  a  folding  of  these  ligaments  which 
assumes  the  form  of  a  dihedral  angle,  open  below,  and  of  which 
the  summit  corresponds  to  the  junction  of  the  upper  and  lower 
forceps. 


OPERATIVE  TECH  NIC  249 

If  the  operation  has  gone  along  smoothly  and  typically,  these 
four  forceps  are  quite  sufficient  to  secure  hemostasis. 

It  is,  however,  not  always  thus.  In  any  case,  before  regarding 
the  operation  as  terminated  and  doing  the  dressing,  it  is  necessary 
to  make  a  serious  examination  of  the  parts.  To  do  so,  separate 
one  from  the  other  two  groups  of  forceps,  which  are  doing  duty 
as  lateral  retractors.  Place  anteriorly  and  posteriorly  two  long 
and  narrow  specula  and  writh  a  tampon  of  gauze  held  in  a  pair 
of  forceps,  proceed  to  the  toilet  of  the  parts.  One  is  thus  able 
to  see  if  any  oozing  is  going  on.  If  oozing  exists,  we  must  find 
the  bleeding  point  and  arrest  it.  If  wre  are  quite  sure  that  the 
hold  of  the  four  chief  forceps  is  perfect,  the  bleeding  may  have 
nmny  origins.  It  may  come  from  tears  produced  during  separa- 
tion of  the  adnexa;  these  tears  are  usually  on  the  posterior  aspect 
of  the  broad  ligaments.  It  may  come  from  the  summit  of  the 
dihedral  angle  formed  by  the  folding  of  the  broad  ligament;  in 
these  cases  the  blood  comes  from  the  arteriole  of  the  round  liga- 

o 

ment  which  has  escaped  the  forcipressure  of  the  upper  clamp. 
Finally,  the  vaginal  incision  may  be  the  source  of  the  hemorrhage. 
In  any  case,  if  the  source  of  the  hemorrhage  has  been  discovered, 
it  is  easy  to  apply  forcipressure  to  the  bleeding  vessel.  Then 
we  again  turn  our  attention  to  the  bleeding,  and  if  hemostasis  is 
absolute,  we  go  on  to  the  dressing. 

This  is  done  with  several  precautions  with  the  aid  of  a  long  pair 
of  vaginal  dressing  forceps.  Two  long  strips  of  iodoform  gauze 
are  introduced.  These  gauze  wicks  should  not  go  beyond  the  end 
of  the  clamps  in  such  a  manner  as  to  prevent  the  contact  of  these 
latter  with  the  intestines  and  finally  to  separate  as  widely  as  possi- 
ble the  intestine  from  the  ligamentous  stumps.  The  exterior 
extremity  of  the  gauze  is  folded  up  in  the  vagina.  A  new  gauze 
is  interposed  between  the  forceps  and  the  fourchette  in  order  to 
prevent  the  direct  pressure  of  forceps  on  the  mucous  membrane 
and  to  thus  avoid  the  production  of  little  excoriations  at  this  point. 
These  are  always  painful  and  present  a  source  of  infection.  The 
patient's  bladder  is  catheterized,  the  vulva  very  carefully  cleaned, 
and  then  covered  over  with  a  large  layer  of  hydrophile  wool,  in  the 
center  of  which  is  an  opening  to  allow  passage  for  the  vaginal 
forceps.  A  T-shaped  bandage  completes  it  all;  finally,  be  careful 
to  unite  the  handles  of  the  forceps  with  a  piece  of  gauze  loosely  tied. 


250  VAGINAL   HYSTERECTOMY 

Postoperative  Details. — The  patient  is  kept  quietly  in  bed 
in  order  to  avoid  any  movement  which  may  affect  the  forceps. 
Raise  the  patient  slightly  so  that  the  forceps  do  not  repose  on  the 
bed.  The  two  thighs  of  the  patient,  united  \vith  a  broad  serviette, 
are  maintained  in  flexion  by  a  pillow  placed  under  the  popliteal 
spaces. 

The  immediate  postoperative  treatment  is  nothing  special. 
It  is  that  of  any  operation  in  which  the  peritoneal  cavity  is  opened. 
Abstinence  from  food  until  evening :  then  alcoholic  fluid  (cham- 
pagne or  grog),  taken  in  small  quantities  at  regular  intervals. 
As  early  as  the  day  following,  give  liquid  alimentation  if  no 
inflammatory  complication  occurs. 

The  patient's  bladder  should  be  catheterized.  This  should 
be  done  at  intervals  and  is  of  much  greater  benefit  than  to  leave 
it  in  continually,  a  course  we  must  deprecate.  A  nurse  should 
remain  by  the  bed,  watch  the  patient's  movements  and  keep  her 
on  her  back. 

Certain  surgeons  apply  an  ice-bag  continually  to  the  abdomen 
in  order  to  lessen  the  pain. 

The  forceps  are  taken  off  forty-eight  hours  after  the  operation. 
This  is  done  very  simply.  Each  clamp  is  carefully  undamped; 
then  a  slight  movement  of  rotation  is  given  to  it  in  order  to  detach 
the  blades  from  the  tissues  with  which  they  were  in  contact. 
This  being  done,  the  clamp  is  gently  drawn  out,  without  jerks, 
and  above  all  without  force.  If  in  spite  of  these  precautions, 
one  finds  difficulty  in  removing  the  forceps,  do  not  insist.  Un- 
clamp  and  take  away  the  neighboring  ones;  that  suffices  often  to 
render  easily  removed  the  recalcitrant  pair.  Afterward,  after 
removal  of  the  forceps,  proceed  to  a  rapid  cleaning  of  the  vulva 
and  once  more  re-apply  a  layer  of  sterilized  wool. 

The  gauze  wicks  are  removed  on  the  fourth  or  fifth  day.  To 
remove  them,  the  patient  is  taken  to  the  operating  theater.  This 
permits  of  washing  the  vulva  with  more  care  and  enables  the 
vagina  to  be  thoroughly  cleansed  before  the  insertion  of  new 
gauze  dressing,  which  will  be  purely  vaginal  now. 

Commence  vaginal  injections  on  the  eighth  or  tenth  day.  The 
cannula  should  be  hardly  made  to  enter  the  vagina,  the  vulva  is 
maintained  open  and  the  pressure  reduced  to  a  minimum.  The 
patient  may  get  up  on  the  fifteenth  day. 


OPERATIVE  TECHNIC  251 

Operative  Difficulties. — The  vaginal  hysterectomy  may  be 
very  difficult  by  reason  of  the  tightness  of  vulva  and  vagina, 
by  fixation  of  the  uterus,  by  its  friability  and  adhesions  round 
about. 

When  the  narrowness  of  vulva  and  vagina  is  not  too  consider- 
able, simple  dilatation  with  specula  at  the  commencement  of  the 
operation  suffices  to  give  them  sufficient  dimensions.  But  if  the 
stricture  of  the  parts,  congenital  or  acquired,  presents  a  very 
marked  degree,  it  is  necessary  to  change  the  constricted  nature 
of  these  tissues  before  thinking  of  a  vaginal  hysterectomy.  The 
different  varieties  of  vaginal  incision  and  separation,  which  we 
have  had  occasion  to  describe,  appear  to  us  to  be  indicated 
only  exceptionally.  It  may  be  sufficient  to  use  repeated  tam- 
poning of  the  vagina  or  to  dilate  it  with  Gariel's  pessary.  We 
should  not  hesitate  to  employ  these  means;  it  is  better,  however, 
in  these  cases  to  use  the  abdominal  route. 

The  uterus  is  usually  fixed  by  peri-uterine  inflammatory 
lesions.  It  constitutes  an  operative  complication  of  the  most 
annoying  description  and  renders  the  drawing  down  of  the 
uterus  so  difficult  that  one  has  to  have  recourse  to  morcellement 
of  the  organ. 

The  difficulties  are  maximum  when  to  this  fixation  of  the 
uterus  is  added  friability  of  tissues.  It  is  then  quite  impossible  to 
attach  a  pair  of  traction  forceps  without  tearing  out  a  piece  of  the 
tissue.  This  friability  occurs  in  hysterectomies  soon  after  a 
pregnancy  or  abortion;  it  may  also  be  seen,  apart  from  preg- 
nancies, in  cancer  of  the  uterus  and  in  some  special  forms  of 
parenchymatous  metritis.  We  must  then,  according  to  J.  L. 
Faure,  replace  traction  forceps  by  forceps  \vith  a  broad  blade, 
such  as  are  used  in  ovarian  cysts.  The  large  hold  prevents  the 
cervix  from  being  torn. 

We  will  not  insist  on  the  difficulties  due  to  adhesions  of  the 
adnexa,  as  we  will  return  to  this  point  when  we  study  vaginal 
hysterectomy  in  case  of  salpingo-ovaritis. 

In  a  general  way,  with  patience  and  method,  wre  can  triumph 
over  these  difficulties.  If,  however,  they  are  too  considerable,  do 
not  continue  too  long  on  an  operation  which  is  so  difficult,  but 
abandon  it  for  the  abdominal  route. 


252  VAGINAL   HYSTERECTOMY 

Complications.— We  may  come  across,  during  or  after  a  hys- 
terectomy, a  certain  number  of  complications  which  it  would  be 
well  to  go  into. 

Hemorrhages. — The  most  important  complication  is  hemor- 
rhage. It  may  come  on  during  the  performance  of  vaginal 
hysterectomy  and  results  generally  from  some  operative  error.  If 
one  takes  care  to  proceed  in  a  methodical  manner,  clamping  the 
ligaments  before  cutting  them,  and  to  proceed  always  under  direct 
control  of  the  eye,  there  is  every  chance  of  avoiding  hemorrhage 
during  the  operation. 

If  the  hemorrhage  comes  on  some  little  time  after  the  opera- 
tion, it  is  due  generally  to  breaking  or  slackening  of  the  hold  of 
one  of  the  clamps  which  assures  the  hemostasis  of  the  broad  liga- 
ments. It  comes  on  usually  when  one  uses  long-bladed  forceps, 
and  wrhen  one  has  applied  only  a  single  forceps  on  each  broad 
ligament.  In  the  procedure  we  have  advised,  by  using  two 
shorter-bladed  forceps,  all  such  accidents  may  be  in  that  manner 
avoided. 

In  presence  of  a  hemorrhage  due  to  this  cause,  seize  the  point 
that  bleeds  through  the  vagina.  But  most  important  to  remember, 
do  not  work  in  the  dark.  The  patient  should  be  anesthetized, 
if  necessary,  and  conveyed  to  the  theater.  The  specula  expose 
the  operative  field.  Do  not  forget  that  these  attempts  to  secure 
secondary  hemostasis  have  often  wrounded  the  ureter;  for  this 
reason  do  not  pinch  up  a  part  with  the  forceps  until  one  is  quite 
sure  of  all  freedom  from  danger.  Prepare  as  for  an  abdominal 
celiotomy.  If  the  attempts  to  arrest  hemorrhage  by  the 
vaginal  route  remain  fruitless,  do  not  hesitate  but  search  for  the 
bleeding  point  by  operating  through  the  abdomen. 

The  hemorrhages  which  succeed  the  removal  of  the  forceps 
are  justifiable  of  a  similar  line  of  action.  It  has  been  recom- 
mended that,  in  order  to  avoid  this  complication,  one  should  un- 
clamp  the  forceps,  and  leave  them  in  position  for  about  an  hour 
afterward.  If  hemorrhage  recurs,  nothing  is  easier  than  to 
reclamp. 

This  procedure  is  little  practised  and  it  is  dangerous  also.  A 
loop  of  intestine  may  come  between  the  separated  blades  and  be 
imprisoned  at  the  moment  of  reclamping.  Like  all  these  blind 
manipulations,  they  should  be  avoided. 


OPERATIVE  TECHNIC  253 

The  hemorrhages  which  come  on  about  the  thirteenth  or 
fourteenth  day  come  from  infection  as  in  all  secondary  hemor- 
rhages. They  should  be  treated  with  tampons  of  iodoform  gauze. 

Lesion  of  Neighboring  Organs. — A  certain  number  of  organs 
may  be  injured  during  the  operation. 

Wound  of  the  ureter  is  rare  in  the  hands  of  an  experienced 
surgeon.  In  450  vaginal  hysterectomies,  Segond  only  had  two 
cases.  In  the. great  majority  of  cases  it  is  the  right  ureter  which 
is  injured  and  the  reason  will  be  seen  later. 

The  ureter  may  be  wounded  in  the  incision  of  the  cervix. 
This  particular  section  of  the  ureter  is  exceptional  and  it  is  easy 
to  avoid  by  incising  the  vagina  on  the  cervix  itself,  and  at  a  little 
distance  from  the  external  os. 

Much  more  frequently  the  ureter  is  wounded  during  forci- 
pressure  on  the  interior  portion  of  the  broad  ligaments.  This 
inclusion  of  the  ureter  has  two  reasons:  first,  an  insufficient 
liberation  of  the  anterior  face  of  the  uterus  and  broad  ligament; 
second,  to  a  too  oblique  attachment  of  the  clamp. 

It  is  shown  that  when  the  uterus  is  drawn  down  toward  the 
vulva,  it  tends  to  become  enclosed  between  the  two  ureters,  and 
that  these,  normally  separated  from  the  cervix  for  a  distance  of 
12  to  15  mm.  come  to  lie  in  contact  with  the  uterus  at  the  level 
of  the  isthmus.  The  freeing  of  the  anterior  surface  of  the  uterus 
and  of  the  broad  ligaments  corrects  somewhat  this  displacement 
and  throws  the  ureter  outward.  The  lateral  incisions,  added 
by  Segond  to  the  circular  incision  wrhich  circumscribes  the  cervix, 
facilitate  greatly  this  pressing  back  of  the  ureter,  in  permitting 
the  separation  of  the  uretero-vesical  and  utero-vaginal  planes 
laterally. 

If  one  thinks  of  the  inconvenience  of  placing  clamps  in  the 
oblique  position,  it  is  enough  to  make  one  avoid  this  operative 
mistake.  If  one  represents  the  position  of  the  hands  of  the  oper- 
ator at  the  moment  of  clamping  the  right  broad  ligament,  it  is 
easy  to  grasp  why  one  is  more  exposed  to  commit  the  mistake  on 
the  right  side.  This  explanation  also  suffices  to  explain  the 
great  frequency  of  lesions  of  the  ureter  on  this  side. 

Still  wre  do  not  think  it  right  to  blame  such  and  such  an 
operative  procedure,  and  the  reproaches  directed  to  the  opera- 
tion by  "  bascule, "  or  inversion  of  the  uterus  without  preliminary 


254  VAGINAL  HYSTERECTOMY 

amputation  of  the  cervix,  such  as  Doyen  does,  do  not  appear  to 
be  founded. 

Finally,  the  urethra  is  above  all  exposed  to  be  pinched  up  in 
the  course  of  atypical  manipulations,  resulting  from  an  abnormal 
anatomical  disposition  of  parts  or  an  unforeseen  operative 
complication.  In  one  case  it  may  be  due  to  the  commencement 
of  an  invasion  of  the  broad  ligament  by  a  neoplasm  which  obliges 
one  to  place  the  clamps  laterally;  in  another  cas^e,  it  is  a  hem- 
orrhage due  to  improper  application  of  a  pair  of  forceps  or  to  the 
slipping  off  of  forceps,  which  leads  us  to  add  a  supplementary 
pair.  For  these  abnormal  circumstances,  it  is  impossible  to 
give  precise  rules  of  action.  It  is  well  to  recall  that  in  these 
atypical  cases  it  is  particularly  the  case  to  avoid  proceeding  in  a 
blind  manner,  and  not  under  control  of  the  eye. 

If  the  ureter  is  cut  across,  the  urine  commences  to  run  into 
the  vagina  some  hours  after  the  operation.  But,  as  most  often 
the  ureter  is  injured  by  being  pinched  up,  the  discharge  is  only 
produced  when  the  scar  tissue  comes  away,  from  the  fifth  to  the 
eighth  day.  If  it  is  a  question  of  an  inclusion  laterally,  renal 
pains  more  or  less  severe  may  cause  a  suspicion;  if  from  the 
beginning  of  this  operative  complication,  it  is,  however,  not 
constant. 

We  will  have  occasion  to  return  to  the  treatment  of  these 
uretero- vaginal  fistulas,  following  on  hysterectomy. 

Wounds  to  the  Bladder. — Wound  of  the  bladder  is  more  fre- 
quent. Segond  observed  this  five  times  in  200  cases.  The 
bladder  is  wounded  sometimes  at  the  moment  of  incision  of  the 
anterior  fornix  or  maybe  at  the  moment  of  liberation  of  the  sub- 
peritoneal  portion  of  the  anterior  face  of  the  uterus. 

In  contradistinction  to  utero- vaginal  fistulas,  the  vesico- 
vaginal  one  may  sometimes  heal  spontaneously. 

Wounds  of  the  Rectum. — The  wounds  of  the  rectum  are  far 
from  rare  (nine  cases  in  200  operations,  after  Segond).  Often 
prepared  by  lesions  of  the  rectal  wall,  they  are  often  produced  at 
the  moment  when  one  frees  the  posterior  surface  of  the  uterus. 
They  may  heal  spontaneously;  we  have  already  considered  the 
operative  procedures  for  them. 

Wounds  of  the  Small  Intestine. — The  wounds  of  the  small 


OPERATIVE  TECHNIC  255 

intestine,  much  more  exceptional  (two  cases  in  200,  Segond),  are 
generally  caused  by  the  freeing  of  the  very  adherent  adnexa  and 
are  only  met  in  very  complex  cases. 

Peritonitis. — Septic  peritonitis  is  the  most  serious  of  all  the 
complications  which  come  on  after  vaginal  hysterectomy.  It  is 
the  habitual  cause  of  death  after  that  operation  and  one  can  say 
that  the  percentage  of  deaths  after  vaginal  hysterectomy  practically 
denotes  the  number  of  cases  of  peritonitis  following  on  operation. 

This  complication  has  become  rare  and  is  becoming  rarer. 
The  relative  benign  character  of  vaginal  hysterectomy  from  the 
point  of  view  of  infection  may  cause  astonishment  when  one  thinks 
how  difficult  it  is,  despite  the  precautions  one  takes  to  artificially 
uriite  the  operative  field  from  the  side  of  the  abdominal  cavity. 
This  fact  explains  precisely  that  in  grave  cases  where  suppura- 
tive  lesions  exist,  the  pelvic  cavity  is  isolated  by  adhesions  from  the 
large  peritoneal  cavity;  it  is  explained  also  by  the  large  open 
drainage  route  of  the  vagina.  As  we  will  have  occasion  to  see 
further,  in  studying  the  septic  peritonitis  following  on  celiot- 
omy  we  are  almost  disarmed,  surgically  speaking,  in  the  presence 
of  this  complication. 

Intestinal  Occlusion. — This  usually  results  from  an  adhesion 
of  the  intestine  at  the  vaginal  cicatrix  and  appears  at  a  variable 
epoch  after  the  operation.  One  may  in  these  cases  of  precocious 
occlusion  liberate  the  intestine  by  manipulations  through  the 
vagina.  This  is  most  often  accomplished  by  the  establishment  of 
an  artificial  anus,  or  by  a  colotomy  followed  by  freeing  of  the 
adhesions.  We  have  seen  after  a  simple  fistulation  of  the  intes- 
tine, all  the  occlusion  troubles  disappear  and  the  fistula  close 
spontaneously  afterward.  The  method  of  action  appears  to  be 
indicated  in  certain  cases,  where  the  general  condition  contra- 
indicates  a  more  serious  intervention. 

Eschars. — Sometimes  these  appear  as  sacral  eschars  in 
women  having  undergone  a  vaginal  hysterectomy.  These  are 
said  to  be  lesions  of  the  trophic  order.  We  think  these  bed- 
sores are  only  macerations  of  the  skin,  and  since  that  we  have 
lost  fear  of  moving  the  patients  in  order  to  secure  for  them  the 
necessary  attention  and  cleanliness  this  complication  has  com- 
pletely disappeared  from  our  wards.  With  appropriate  dressings, 
these  eschars  heal  rapidly. 


256  VAGINAL   HYSTERECTOMY 

2.  Various  Procedures. 

Doyen's  Procedure. — We  will  not  insist  on  the  procedure  of 
Doyen.  As  may  be  seen,  it  rests  on  two  fundamental  principles : 
rejection  of  all  preventive  hemostases;  median  anterior  hemisection 
in  order  to  permit  the  uterus  to  be  tilted  forward. 1 

We  will  confine  ourselves  to  remarking  that  Doyen  brings 
about  the  hemostasis  of  the  broad  ligament  with  a  single  pair  of 
very  long  elastic  forceps  which  he  applies  from  above  downward 
along  the  extent  of  the  broad  ligament.  Generally  he  places  a 
second  reinforcing  forceps  internal  to  the  first  part.  We  prefer 
the  technic  we  described  previously  in  this  book.  In  cases  where 
the  adnexa  are  difficult  to  get  at  it  will  be  well  sometimes  to 
continue  anterior  median  hemisection  on  the  posterior  face  as 
far  as  the  cervix.  Each  half  of  the  uterus  attached  to  its  broad 
ligament  is  more  easily  drawn  out. 

Pean's  Procedure. — Preventive  forcipressure  and  morcelle- 
ment  are  the  two  principles  of  Pean.  This  procedure  is  done  in 
the  following  manner:  A  circular  incision  disinserts  the  vagina. 
Then  free  by  separation  the  two  faces  of  the  uterus  and  broad 
ligaments  up  to  a  certain  height,  more  or  less  extensive.  Apply 
forceps  to  the  liberated  portion  of  the  ligaments  which  are  cut 
through  internal  to  the  forceps.  The  fragment  of  uterus  lib- 
erated by  this  partial  section  of  the  broad  ligaments  is  then 
divided  with  strong  scissors  into  two  portions,  one  anterior  and 
the  other  posterior.  One  forceps  is  placed  at  the  base  of  each 
portion  and  the  segment  of  the  uterus  placed  below  the  forceps 
is  excised.  The  same  procedure  is  repeated  on  the  portion  of  the 
uterus  that  lies  above.  Each  stage  may  thus  be  divided  into  four 
principal  parts:  1.  The  freeing  of  the  anterior  surface  of  the 
uterus  from  the  posterior.  2.  The  clamping  and  section  of  the 
broad  ligaments.  3.  The  division  into  two  portions  of  the  por- 
tion of  the  uterus  freed  by  the  preceding  manipulations.  4. 
The  excision  of  the  two  portions  thus  obtained.  We  thus  obtain, 
by  successive  stages,  the  complete  excision  of  the  uterus. 

The  most  important  point  is  never  to  cut  through  a  segment 
of  the  uterus  before  placing  above  it  another  traction  forceps  in 

1  Doderlein  advised  a  median  posterior  hemisection  of  the  uterus.     (Arch.  f.  Gyn.. 
1901,  T.  LXIII,  p.  1.) 


257 

order  to  preserve  always  a  solid  hold,  without  which  the  fundus 
of  the  uterus  may  sharply  disappear  into  the  depths  and  from 
whence  it  could  only  be  recovered  writh  great  difficulty. 

We  must  never  go  away  from  the  median  line  in  the  holds  we 
take  in  order  to  avoid  false  holds,  tears,  hemorrhage  and  wounds 
of  neighboring  organs. 

Segond's   Operation. — It   may   be   summed   up  as  follows 
Segond  commences  the  hysterectomy  like  Pean  and  finishes  like 
Doyen.     He   commences  really   by  excising  the  cervix;  to   do 
this  he  clamps  and  cuts  through  the  lower  portion  of  the  broad 
ligament,  isolated  at  first  on  each  side  of  the  cervix  from  the  pen- 


FIG.  236. — Morcellement  of  the  uterus  (J.  L.  Faure). 

uterine  tissues  (interior  portion  of  the  broad  ligament  with  the 
uterine  artery,  interior  portion  of  the  utero-sacral  ligament  of  the 
same  side).  A  short-bladed  forceps  seizes  the  tissues  on  each 
side  of  the  cervix  and  a  single  cut  of  the  scissors  divides  them 
between  the  forceps  and  the  cervix.  As  the  descent  of  the  uterus 
is  often  limited  by  the  utero-sacral  ligaments,  when  these  are 
sectioned  across,  the  uterus  descends  some  centimeters  and  the 
operation  is  facilitated. 

The  cervix  is  divided  into  two  portions,  one  anterior  and  one 


17 


258  VAGINAL   HYSTERECTOMY 

posterior,  which  are  successively  excised.  This  being  done,  the 
body  of  the  uterus  is  extracted  by  making  its  fundus  descend  by 
virtue  of  a  conoid-shaped  scooping  out  of  the  anterior  wall  or 
simply  thanks  to  a  median  hemisection  of  that  wall.  Segond 
attaches  great  importance  to  the  preliminary  amputation  of  the 
cervix  which  would  constitute,  according  to  him,  the  best  means 
of  putting  out  of.  count  the  possible  injury  of  the  ureters. 

Procedures  of  Quenu  and  Muller. — While  these  two  surgeons 
have  one  identical  manipulation,  the  total  median  sectioning 
across  of  the  uterus,  otherwise  the  procedures  of  Quenu  and 
Muller  cannot  be  compared. 


FIG.  237. — Total  median  hemisection;  two  forceps  draw  down  and  out  the  two  halves 

of  the  cervix. 

In  Muller's  procedure,  the  hemisection  is  done  at  the  end  of 
the  operation  if  the  uterus,  which  has  been  liberated,  has  de- 
scended. It  is  a  complementary  maneuver,  destined  to  facilitate 
the  ligature  of  the  two  broad  ligaments.  It  is  based  on  the 
observation  that  ligature  of  the  second  broad  ligament  is  always 
much  easier  than  that  of  the  first. 

In  Quenu's  procedure  the  hemisection  is  to  enable  the  organ 
to  be  more  easily  drawn  down.  This  maneuver  is  carried  out  at 
the  beginning  of  the  operation  as  it  is  done  in  Doyen's  anterior 
hemisection.  The  uterus,  drawn  upon  by  forceps,  does  not  so 
much  tend  to  flex  forward  as  in  the  median  anterior  section,  but 


VARIOUS  PROCEDURES 


to  open  itself  out,  to  sink  upon  itself,  so  to  speak,  in  the  median 
line,  in  descending  in  the  axis  of  the  pelvis  (Fig.  237).  The  more 
the  two  segments  separate  in  divergence,  and  the  more  the  fundus 
descends,  the  more  does  one  continue  the  median  section  toward 
the  fundus  (Fig.  238)  and  eventually  by  fresh  holds  and  successive 
sections  of  the  uterus  to  completely  divide  it  into  two.  The  rest 


FIG.  238. — While  the  hemisection  ad- 
vances and  the  two  halves  of  the  uterus 
separate  the  fundus  descends  and  comes 
down  to  the  vulva. 


FIG.  239.— One  of  the  halves  of  the 
uterus  has  been  pushed  back  into  the 
pelvis  and  this  permits  of  the  more  easy 
descent  of  the  other. 


of  the  operation  with  relation  to  each  half  is  continued  as  in  the 
procedure  of  Doyen,  the  section  of  the  uterus  has  been  carried 
out  through  the  cervix,  posterior  wall  and  cervix.  It  is  at  times 
of  advantage  when  the  median  section  is  finished  to  press  back 
one  of  the  halves  into  the  pelvis  and  thus  render  the  drawing  down 
of  the  other  easier. 

J.  L.  Faure's  Procedure. — If  the  uterus  does  not  come  down, 
even  after  total  hemisection,  the  fundus  of  the  uterus  remains 
immobile  in  the  pelvis;  then  we  may  sometimes  get  at  the  uterine 
cornua  in  resorting  to  Pean's  morcellement,  and  in  practising 
transverse  segmentation  of  the  uterus.  After  the  median  section  of 
a  part  of  the  uterus,  if  one  does  not  gain  any  more  ground,  one 


260 


VAGINAL   HYSTERECTOMY 


should  cut  across  one  of  the  halves  of  the  uterus.  The  segment, 
constituted  by  the  segment  thus  cut  across,  separates  and  with  a 
forceps  introduced  from  above  upward  along  the  length  of  the 
uterine  border  one  is  able  to  seize  the  upper  portion  of  the  broad 
ligament  up  to  the  cornu  of  the  uterus.  With  a  pair  of  scissors 
detach  this  uterine  cornu  from  its  insertion  into  the  broad  liga- 
ment, and  the  mobilization  of  the  uterus  enables  us  to  conclude 
an  operation  which  appeared  at  first  to  possess  insurmountable 
obstacles. 


FIG.  240. — Transverse  version  of  the  uterus  after  hemisection. 

Ligature  of  the  Broad  Ligaments.  Angiotripsy.  Galvano- 
cautery. — All  the  procedures  we  have  described  have  in  common 
the  hemostasis  of  the  broad  ligaments  by  means  of  a  f  orcipressure, 
which  is  allowed  to  persist  during  a  certain  period  of  time.  The 
ligature  of  the  broad  ligaments  is  generally  rejected  save  in  cer- 
tain exceptional  cases  (hysterectomy  for  prolapse). 

Even  in  Germany,  where  for  a  long  time  fervent  operators 
opposed  it,  they  have  now  accepted  forcipressure.  It  is  not 
without  drawbacks  and  the  clamps  left  in  for  forty-eight  hours 
interfere  considerably  with  the  comfort  of  the  patients.  This 
has  inspired  certain  surgeons  (Doyen,  Tuffier  in  France,  Thumin, 
Amann  in  Germany)  with  the  notion  of  applying  angiotripsy 
to  vaginal  hysterectomy.  Although  this  has  been  successful,  it 


OPERATIVE  MODIFICATIONS  261 

is  not  without  danger;  there  has  been  persistent  oozing,  in  fact 
veritable  hemorrhages  or  even  peritoneal  infection  by  the  falling 
back  into  the  abdomen  of  the  pedicles  which  are  no  longer  held 
in  the  vaginal  wround  by  ligatures  or  clamps.  It  is  generally 
admitted  that  it  is  imprudent  to  apply  it  without  adding  "ligatures 
of  safety"  and  without  closing  up  the  peritoneum  above  the 
stumps  (Doyen).  We  are  precipitated  thus  into  the  position  of 
the  inconvenience  of  ligatures  and  operative  complications. 
Also,  in  spite  of  the  enthusiasm  excited  at  first,  angiotripsy  is 
hardly  ever  employed  as  a  means  of  hemostasis  in  vaginal 
hysterectomy. 

The  employment  of  the  galvano-cautery  advocated  formerly 
byx  Byrne  for  amputation  of  the  cervix,  has  been  recently  put 
forward  by  Werder  for  hysterectomy  in  cancer;  one  avoids,  by 
these  means,  all  local  recurrences.  The  vaginal  mucous  mem- 
brane is  incised  around  the  cervix  with  a  galvano-cautery  at  a 
dull  red  heat ;  the  f ornices  are  opened ;  the  uterus  is  tilted  forward ; 
and  downward  clamps  are  placed  on  the  broad  ligaments  w^hich 
are  after\vard  cut  across.  The  uterus  being  lifted  out,  the  broad 
ligaments  are  drawn  on  and  then  external  to  the  forceps,  Downes' 
electro-thermic  clamps  are  applied.  These  crush  the  tissues  like 
an  angiotribe  and  then  cauterize  the  crushed  parts.1  All  the 
bleeding  points  of  the  wound  are  cauterized  and  recauterized. 
Conclude  the  operation  by  suturing  the  retro-vesical  peritoneum 
to  the  posterior  peritoneum  of  the  pouch  of  Douglas,  leaving  on 
each  side  a  space,  in  order  to  insinuate  along  the  stump  of  the 
broad  ligament  a  dressing  of  iodoform  gauze,  which  is  taken 
out  at  the  end  of  four  or  five  days. 

3.  Operative  Modifications  According  to  the  Nature  of  the  Lesion. 

1 .  Vaginal  Hysterectomy  in  Cancer. — Vaginal  hysterectomy  may 
be  done  either  for  cancers  of  the  cavity  of  the  uterus  or  for  cancers 
of  the  cervix.  In  the  latter  case,  it  is  better  to  do  a  preliminary 
radical  curettage,  removing  all  the  cancerous  vegetations.  The 
curettage  should  be  done  immediately  before  the  hysterectomy, 
may  be  several  days  before,  when  clinical  symptoms  lead  one  to 

1  Cauterization  is  obtained  by  the  action  of  a  band  of  platinum  which  is  doubled 
over  one  of  the  blades  of  the  forceps  and  kept  red  with  an  electric  current.  (Downes, 
Ann.  de  Gynec.,  1903,  T.  I,  p.  355.) 


262  VAGINAL   HYSTERECTOMY 

think  that  there  exists  a  serious  degree  of  infection  of  the  can- 
cerous vegetations.  The  preliminary  curettage  has  a  double 
advantage:  it  permits  us,  first,  to  secure  a  possible  disinfection 
of  the  operative  field  to  a  degree  unknown  of  any  antiseptic 
solutions.  It  has  the  advantage  of  facilitating  the  clinical  ex- 
ploration and  of  enabling  us  to  appreciate  with  more  precision 
than  by  the  bimanual  examination  the  degree  of  extension  of 
the  neoplasm  and  of  seeing  if  a  radical  operation  is  or  is  not 
indicated. 

Vaginal  hysterectomy  for  cancer  wrould  not  have  the  preten- 
sion of  being  a  radical  operation  if  it  only  attacked  the  primary 
focus,  without  being  concerned  with  the  lymphatic  vessels  which 
are  more  frequently  invaded. 

It  should  be  conducted  in  such  a  manner  as  to  excise  the 
entire  primitive  focus  and  to  avoid  the  grafting  of  the  neoplasm 
on  the  raw  surfaces.  This  double  desideratum  dominates  the 
operative  technic  in  cases  of  vaginal  hysterectomy  for  cancer. 

If  it  is  a  question  of  a  cavity  cancer,  circumscribe  the  cervix 
with  the  ordinary  incision.  If  it  is  a  case  of  cancer  of  the  cervix, 
average  case,  commence  by  the  dissection  up  of  a  little  vaginal 
collar,  which  is  prudently  detached  anteriorly  from  the  bladder 
and  posteriorly  from  the  rectum.  Commence  the  operation  by 
freeing  the  bladder,  because  the  invasion  of  this  organ  should  be 
regarded  as  an  operative  contraindication.  In  order  to  find  out 
the  state  of  the  bladder,  commence  by  a  lateral  in  front  of  the 
broad  ligaments.  Move  the  hand  gently  toward  the  median 
line;  if  at  this  level  one  finds  friable  tissue,  stop.  To  pursue  the 
operation  would  lead  to  the  formation  of  a  vesico- vaginal,  in  the 
absence  of  which  one  might  hope  for  a  relatively  durable  result. 

If  the  bladder  is  recognized  as  healthy,  proceed  with  opera- 
tion in  opening  the  recto-uterine  cul-de-sac  and  conclude  by 
anterior  hemisection  procedure,  following  out  the  technic  we 
have  already  indicated.  In  these  particular  cases  of  cancer  of  the 
cervix,  Segond's  procedure  has  the  advantage  of  removing  from 
the  operative  field  the  cancerous  mass  which  may  infect  the  tissues 
and  graft  cancer  anew. 

It  is  generally  conceded  that  the  removal  of  the  adnexa  should 
be  carried  out  because  cases  have  been  reported  of  metastatic 
deposits  in  the  ovaries. 


OPERATIVE  MODIFICATIONS  263 

The  immediate  results  are  the  following: 

In  2156  cases  collected  by  Richot  there  were  175  deaths  or  8 
to  10  per  cent. 

The  operation  does  not  therefore  present  an  extreme  gravity. 
Unhappily  the  later  results  are  more  mediocre.  In  F.  Ferrier's 
work  the  recurrences  have  been  70  per  cent. ;  according  to  Zweifel, 
65  per  cent.,  and  Olshausen,  61  per  cent. 

The  recurrence  is  above  all  in  the  first  year  that  follows  the 
operation;  the  frequency  diminishes  gradually  as  the  interval 
lengthens,  as  the  following  table  of  recurrences  compiled  by 
Segond  shows: 

The  recurrence  occurred  14  times  in  the  first  year. 
The  recurrence  occurred    9  times  in  the  second  year. 
The  recurrence  occurred    5  times  in  the  third  year. 
The  recurrence  occurred    0  times  in  the  fourth  year. 
The  recurrence  occurred    1  time  in  the  fifth  year. 

After  five  years  the  cure  may  be  regarded  as  certain.  But 
Segond  observed  one  recurrence  after  seven  years. 

The  recurrences  are  almost  always  seen  in  the  vaginal  wall, 
near  the  scar  in  the  cicatrix  itself  or  a  little  above  it,  probably  due 
to  the  implanting  of  cancerous  grafts  during  excision.  These 
local  recurrences  induced  Werder  to  resort  to  excision  by  galvano- 
cautery. 

2.  Vaginal  Hysterectomy  in  Fibromata. — This  is  often  done 
for  fibromata.  We  will  see  that  it  loses  ground  more  and  more 
and  tends  to  be  replaced  in  the  majority  of  cases  by  abdominal 
hysterectomy. 

One  point  dominates  all  the  technic  of  vaginal  hysterectomy 
for  fibromata :  it  is  the  great  importance  of,  one  might  almost  say 
imperative  nature  of,  morcellement. 

This  morcellement  has  a  double  end  in  view:  To  diminish 
the  volume  of  the  tumor  and  to  permit  it  to  pass  through  the 
vaginal  tissues  and  reduce  the  uterus  to  a  flexible  shell,  so  to 
speak,  which  will  tilt  forward  as  in  the  way  a  uterus  of  normal 
dimensions  does  after  a  simple  anterior  hemisection. 

It  is  evident  that  the  manipulations  which  give  this  double 
result  may  vary  according  to  each  case.  Some  smaller  fibro- 
mata, easily  accessible,  may  be  torn  out  with  the  first  pressure 


264 


VAGINAL   HYSTERECTOMY 


applied  to  the  traction  forceps,  which  seizes  them  and  draws 
upon  them  at  the  same  time  imparting  to  them  a  twist.  If  the 
fibromata  are  larger.,  more  solidly  attached,  then  we  wrould  resort 
to  morcellement  with  the  bistoury  or  scissors,  aiding  ourselves 
as  required  by  the  corkscrew  and  evacuating  conoid-shaped 
masses  of  tissue.  If  the  fibromata  are  situated  high  up  and 
inaccessible,  we  commence  by  excising  a  V-shaped  area  of  uterine 
tissue.  (See  before,  morcellement  in  vaginal  myomectomy.) 

The  uterus  is  attacked  on  its  anterior  surface.  The  anterior 
wall  is  resected  over  a  more  or  less  extended  area;  this  resection 
admits  of  successive  enucleation  of  different  fibromatous  masses 
writh  or  without  morcellement. 


FIG.  241. — Morcellement  of  the  anterior  face  of  the  uterus  (Doyen).     The  segments 
1,  2,  3,  etc.,  are  successively  excised. 

The  general  shape  of  the  resected  area  is  a  V  with  the  sum- 
mit below  (Fig.  241). 

In  these  manipulations  there  is  never  need  to  excise  a  frag- 
ment of  the  mass  without  having  as  preliminary  placed  a  traction 
forceps  on  the  part  immediately  above. 

In  a  general  way  the  commencement  of  the  operation  is 
difficult;  beginning  by  removing  very  small  pieces,  one  proceeds 
to  greater  and  greater.  At  length  we  have  a  uterus  emptied  of 
all  the  fibromata  it  contained  and  of  which  the  anterior  wall  has 
in  a  great  measure  disappeared.  Nothing  is  simpler  than  to 


OPERATIVE  MODIFICATIONS  265 

lever  up  the  uterus  and  then  apply  forcipressure  to  the  broad 
ligaments  as  usual. 

This  method  of  procedure  appears  to  be  superior  to  that  in 
which  the  fibromatous  uterus  is  resected  by  successive  stages, 
with  forcipressure  and  preliminary  section  of  the  corresponding 
portion  of  the  broad  ligaments,  as  in  Pean's  operation. 

In  1369  vaginal  hysterectomies  for  fibroma,  Richelot  had  63 
deaths,  giving  4.6  per  cent. 

Segond,  whose  experience  and  skill  in  vaginal  surgery  is  so 
well  known,  gives  results  of  15  per  cent,  of  deaths  in  vagina] 
hysterectomy  for  fibroma. 

These  differences  may  be  explained  by  the  fact  that  Segond 
pushes  to  excess  the  vaginal  operative  route  and  thus  in  attempt- 
ing very  difficult  cases  acquires  a  higher  mortality. 

3.  Vaginal  Hysterectomy  in  Inflammation  of  the  Adnexa.— 
It  is  known  that  Pean  regarded  the  excision  of  the  uterus  as  the 
essential  stage  in  the  treatment  of  inflammations  of  the  adnexa  by 
the  vaginal  route.  We  excise,  to  use  his  expression,  "la  bonde, " 
the  bung  literally  which  closes  the  suppurating  peri-uterine 
pockets;  these  being  freely  drained  by  the  preliminary  excision 
of  the  uterus,  heal  perfectly  without  any  call  for  their  individual 
extirpation.  This  is  a  mistake ;  we  have  on  many  occasions 
excised  the  entire  uterus  without  opening  any  peri-uterine  sup- 
purative  foci.  For  this  reason,  modern  surgeons  prefer  to  excise 
the  diseased  adnexa  writh  the  uterus. 

It  is  certain  that  this  excision  is  difficult  and  often  even  impos- 
sible. But  systematic  attempts  at  excision,  even  when  they  fail, 
have  the  advantage  of  preventing  a  suppurating  focus,  remain- 
ing unopened  in  spite  of  the  excision  of  the  uterus. 

In  excision  of  the  adnexa  during  vaginal  hysterectomy,  free 
these  by  the  hand.  They  are  separated  behind  the  posterior 
surface  of  the  broad  ligaments,  and  we  then  endeavor  to  draw 
them  toward  the  fundus  of  the  uterus.  Surgeons  with  knowl- 
edge of  the  vaginal  route  generally  succeed  in  the  extirpation  in 
the  majority  of  cases  (Segond,  55  times  in  77  cases;  Bouilly, 
45  times  in  52  cases;  Jacobs,  372  times  in  421  cases). 

The  immediate  results  of  vaginal  hysterectomy  for  diseased 
adnexa  are  the  following:  In  1113  cases  collected  by  Bardenheuer, 


266 


VAGINAL   HYSTERECTOMY 


he  had  39  deaths,  giving  about  3.5  per  cent.     Particular  statistics 
give  an  average  mortality  slightly  higher. 

Richelot,  307  operations,  15  deaths;  4.87  per  cent. 
Segond,  200  operations,  14  deaths;  7  per  cent. 
Reynier,  52  operations,  6  deaths ;  1 1  per  cent. 
Bouilly,  51  operations,  3  deaths;  5.8  per  cent. 

4.  Hysterectomy  in  Puerperal  Infection. — The  puerperal 
uterus  is  very  friable;  its  cervix  tears  under  traction  of  toothed 
forceps,  which  are  usually  employed  for  the  drawing  down  of 


FIG.  242. — Puerperal  hysterectomy.     The  friable  uterus  is   seized  with  cyst  forceps 

(J.  L.  Faure). 

the  uterus.  After  successive  holds  the  cervix  is  lacerated, 
becomes  unrecognizable  and  unfit  as  a  hold  in  order  to  do 
the  operation.  All  these  inconveniences  disappear  if,  as  J.  L. 
Faure  advises,  one  uses  broad-bladed  cyst  forceps  instead  of 
the  toothed  variety.  The  large  hold  prevents  the  cervix  from 
tearing.  In  women  recently  "accouchees"  with  a  large  vagina 
and  a  supple  uterus  the  operation  is  of  the  easiest  if  one  draws 
gently  on  the  uterus  without  force.  The  uterus  flexes  forward 
with  the  greatest  facility  and  the  operation  is  terminated  very 
rapidly. 

5.  Vaginal   Hysterectomy   for   Prolapse. — Vaginal   hysterec- 


OPERATIVE  MODIFICATIONS 


267 


tomy  is  rarely  practised  for  prolapse;  it  is  only  exceptionally 
indicated  in  the  treatment  of  this  affection. 

The  technic  of  hysterectomy  in  these  cases  presents  some 
peculiarities  by  reason  of  the  special  anatomical  conditions  we 
find. 

1.  The  replacing  of  continuous  forcipressure  by  ligatures,  the 
broad  ligaments  being,  as  the  result  of  the  drawing  out  of  the 
uterus,  very  accessible. 

2.  The  necessity  of  making  at  the  same  time  as  an  excision 
of  the  uterus  a  large  excision  of  the  vagina,  since  this  canal  under- 


FIG.  243. — The  posterior  denudation  traced  (Asch). 

goes  a  considerable  increase  in  size  as  the  result  of  the  prolapse. 
Fritsch's  Procedure. — To  do  this  operation  draw  strongly  on 
the  cervix  upward  and  forward.  A  V-shaped  incision  is  then 
made  with  the  summit  pointing  posteriorly  at  the  level  of  junction 
of  the  posterior  third  with  the  anterior  two-thirds  of  the  pos- 
terior vaginal  wall  (Fig.  243).  The  pouch  of  Douglas  is  opened 
and  the  peritoneum  is  sutured  to  the  posterior  lip  of  the  incision. 
It  is  then  easy  to  draw  the  fundus  of  the  uterus  into  the  wound. 
The  broad  ligaments  are  tied  off  in  stages  commencing  from 
above,  aud  removing  if  possible  the  adnexa.  It  only  remains 
to  separate  off  the  bladder  and  to  resect  the  anterior  vaginal 
wall. 


268 


VAGINAL   HYSTERECTOMY 


The  cervix  is  now  strongly  drawn  downward,  and  a  U-shaped 
incision  is  made  in  the  vagina  with  the  convexity  corresponding 
to  the  ureter  (Fig.  244),  and  the  mucous  membrane  is  separated 
up  from  this  almost  to  the  cervix.  This  is  done  partly  with  a 
scalpel  and  partly  by  the  finger.  This  stage  of  the  operation 
is  difficult,  especially  when  anterior  colporrhaphies  force  us  to 
work  in  cicatricial  tissue. 

Once  the  cervix  is  reached,  we  may  operate  from  above 
downward  by  the  vesico-uterine  cul-de-sac.  If  the  adhesion  to 


FIG.  244. — The  anterior  denudation  traced  (Asch). 

the  bladder  is  too  firm  separate  off  a  thin  layer  of  uterine  tissue. 

The  uterus  having  been  excised  with  the  two  large  anterior 
and  posterior  flaps  of  vaginal  mucous  membrane  attached  to  it, 
the  two  lips  resulting  from  the  resection  of  the  mucous  mem- 
brane of  the  anterior  wall  of  the  vagina  are  united  transversely; 
then,  after  having  reduced  the  bladder,  it  is  covered  over  again 
with  vesico-uterine  peritoneum  which  is  sutured  to  the  mucous 
membrane  of  the  vagina.  Further,  the  pedicles  of  the  broad 


OPERATIVE  MODIFICATIONS  269 

ligaments  are  sutured  to  the  vagina  on  each  side  and  thus  keeping 
it  in  suspension. 

The  non-obliterated  peritoneal  cavity  is  tamponed  with 
iodoform  gauze.  The  operation  is  concluded  with  a  recon- 
struction of  the  perineum. 

Doyen's  Procedure. — Acting  on  the  observation  that  the 
pouch  of  Douglas  is  always  easily  accessible  when  the  inferior 
border  of  the  bladder  is  sometimes  difficult  to  make  out  amidst 
the  hypertrophied  and  indurated  tissues  that  surround  it,  Doyen 
commences  by  opening  the  peritoneum  posteriorly.  He  cuts 
across  the  mucous  membrane  transversely  at  the  level  of  the 
old  posterior  fornix  of  the  vagina.  As  soon  as  the  lips  of  the 
mucous  membrane  open  out,  he  makes  in  the  median  line  pos- 


FIG.  245. — Totality  of  excised  parts  (Asch). 

teriorly  a  longitudinal  incision  w7hich  opens  the  inferior  portion 
of  the  pouch  of  Douglas.  After  enlarging  the  peritoneal  open- 
ing with  the  ringers,  he  hooks  up  the  fundus  of  the  uterus  and, 
making  it  tilt  forward,  he  draws  it  outside. 

A  longitudinal  hemisection  carried  out  on  the  posterior 
aspect  of  the  uterus  is  continued  on  to  the  fundus  and  then  on  to 
the  anterior  aspect.  The  uterus  and  bladder  are  separated 
with  the  finger  or  a  blunt  instrument  and  then  after  completing 
the  hemisection  the  anterior  fornix  is  opened.  The  circum- 
ference of  the  cervix  is  freed  by  the  dissection  of  a  collarette  of 
the  vagina.  The  two  halves  of  the  uterus  are  now  only  held 
by  the  broad  ligaments. 

After  giving  each  of  these  halves  a  torsion  of  180  degrees, 


270  VAGINAL  HYSTERECTOMY 

imparting  to  each  broad  ligament  the  appearance  of  a  spiral 
cord,  these  cords  are  crushed,  ligatured,  and  cut  below  the  liga- 
ments. Then  he  closes  by  a  purse-string  suture,  which  in  pass- 
ing through  the  broad  ligaments,  takes  up  the  peritoneal  collar- 
ette. He  excises  the  largest  part  of  the  anterior  wall  of  the 
vagina  and  does  an  anterior  colporrhaphy  and  concludes  with  a 
colpo-perineorrhaphy. 

Results. — Considering  the  weakness  generally  found  among 
patients  operated  on  for  prolapse,  the  hysterectomy  gives  a 
fairly  elevated  mortality  of  five  deaths  in  57  cases  we  have 
collected,1  which  number  is  a  little  higher  than  that  given  person- 
ally by  Kirchgessner,  who  in  40  cases  had  three  deaths.2 

The  later  results,  if  one  is  confined  to  the  excision  of  the 
uterus  and  of  the  vagina,  have  been  mediocre;  it  has  also  been 
found  necessary  to  add  drastic  perineal  operations  to  the  excision 
of  the  uterus. 

In  these  conditions  it  is  understood  that  we  reserve  this 
operation  to  the  cases  where  a  lesion  of  the  organ  exists  (gangrene, 
fibroma,  cancer) ,  which  suffices  in  itself  to  render  excision  neces- 
sary, and  to  those  cases  where  the  uterus  is  constantly  external, 
extensively  ulcerated,  and  is  the  origin  of  various  discharges, 
mucopurulent  or  sanguineous,  and  in  women,  either  at  or  past 
the  menopause. 

6.  Vaginal  Hysterectomy  in  Uterine  Inversion. — The  opera- 
tive technic  differs  according  as  whether  inversion  is  incomplete 
or  complete. 

In  incomplete  inversion  seize  the  cervix  writh  two  traction 
forceps  attached  at  the  level  of  the  commissures.  Circum- 
scribe the  cervix  with  a  circular  incision,  penetrate  the  posterior 
cul-de-sac,  then  explore  the  pelvic  cavity  and  determine  the 
anatomical  disposition  of  the  uterus.  Then  pass  to  the  liberation 
of  the  anterior  part. 

Split  the  cervix  in  the  median  line  anteriorly.  Then  see  if 
that  incision  is  not  sufficient  to  secure  the  reduction  of  the  in- 
version of  the  uterus.  If  the  reduction  is  impossible,  continue 
the  operation  by  opening  the  anterior  cul-de-sac.  Nothing  is 

1  Hartmann  and  du  Bouchet,  Vaginal  Hysterectomy  in  Treatment  of  Uterine  Pro- 
lapse.    Annales  de  gyn.,  Paris,  1894,  T.  I,  p.  45. 

2  Ph.  Kirchgessner,  Complete  Vaginal  Extirpation  in  Complete  Uterine  Prolapse. 
Zeitschr.  f.  Geb.  u.  Gyn.,  Stuttgart,  1906,  T.  LVIII,  p.  230. 


OPERATIVE  MODIFICATIONS  271 

simpler  than  tying  or  seizing  the  broad  ligaments  in  a  pair  of 
forceps  and  of  separating  off  the  uterus. 

If  the  inversion  is  complete,  the  commencement  of  the 
hysterectomy  may  be  delicate.  Do  a  circular  incision  at  the 
level  of  the  cervix,  which  may  be  determined  by  palpation. 

Open  the  posterior  fornix  as  soon  as  the  peritoneum  is 
opened,  introduce  the  finger  into  the  peritoneal  cavity  and 
draw  it  in  front  of  the  cervix.  Then  with  the  finger  open  the 
anterior  fornix  cautiously.  When  the  uterus  is  freed  ante- 
riorly, the  operation  may  be  pursued  without  difficulty  as  in 
incomplete  inversion. 

7.  Vaginal  Hysterectomy  for  Juxta -uterine  Tumors. — Vaginal 
hysterectomy  may  be  done  during  the  course  of  an  operation  for 
excision  of  a  juxta-uterine  tumor. l 

Two  cases  present  themselves:  Either  the  tumor  is  supra- 
uterine  and  the  hysterectomy  is  done  in  order  to  create  a  way 
of  access;  the  hysterectomy  is  then  spoken  of  as  preliminary  or 
the  tumor  is  rather  more  intrauterine  and  its  excision  may  be 
carried  out  without  a  preliminary  hysterectomy.  But  this 
removal  leaves  a  denuded  uterus,  badly  fixed,  and  the  comple- 
mentary hysterectomy  is  required.  In  the  latter  case  hysterec- 
tomy has  the  advantage  of  creating  an  extensive  drainage  canal. 

In  spite  of  some  successes  obtained  with  this  manner  of 
operating,  relative  successes  really,  since  Segond  had  two  deaths 
in  twenty-five  cases,  making  a  mortality  of  8  per  cent.,  we  believe 
that  the  abdominal  route  is  Jess  grave  and  should  be  done  when- 
ever we  are  in  the  presence  of  tumors,  manifestly  of  the  adnexa, 
however  small  they  may  be.  We  must  apologize  for  the  long 
dissertation  on  vaginal  hysterectomy. 

The  great  place  it  has  occupied  in  the  history  of  gynecology 
justifies  the  developments  we  have  consecrated  to  it.  While  con- 
vinced partisans  of  the  abdominal  route  in  the  immense  majority 
of  cases,  we  believe  that  vaginal  hysterectomy  may  still  be  of  great 
service  in  particular  cases. 

In  inveterate  uterine  prolapse  with  extensive  lesions  on  the 
cervix,  in  certain  cases  of  irreducible  uterine  inversions,  in  rare 
acute  or  virulent  pelvic  suppurations,  where  colpotomy  is  insuf- 

1  Segond,  Bilateral  Tumors  of  the  Adnexa  that  are  Suited  for  Excision  by  the  Vaginal 
Route  after  Hysterectomy.  Revue  de  gynecologic,  Paris,  1897,  p.  205. 


272  VAGINAL   HYSTERECTOMY 

ficient  to  arrest  the  inarch  of  invasion  of  the  disease,  and  in 
puerperal  infection,  vaginal  hysterectomy  preserves  its  superiority. 
It  is  even  indicated  in  certain  cases,  ordinarily  justifying  the 
abdominal  route,  when,  for  example,  the  patient  is  very  stout 
and  the  uterus  is  small,  mobile  and  may  be  so  easily  extirpated 
from  below. 

The  annoyance  to  the  operator  of  adipose  excess  of  the 
abdominal  wall,  and  the  difficulty  of  obtaining  a  quiet  anesthesia 
with  regular  breathing  are  strong  arguments  in  favor  of  vaginal 
hysterectomy. 

We  will  not  insist  on  the  choice  of  procedure  as  it  depends  on 
the  case;  that  which  we  have  already  said  in  reference  to  each 
enables  one  to  decide  what  to  do  without  our  returning  to  the 
question. 


CHAPTER  IX. 

HYSTERECTOMY  BY  THE  PARAVAGINAL  ROUTE. 
Summary. — History. — Operation. — Results  and  indications. 

History. — The  paravaginal  route,  advised  by  Karl  Schuch- 
ardt,1  has  for  its  purpose  the  creation  of  a  free  path  of  access 


FIG.  246. — Dissection  of  a  vaginal  collarette  (Proust) . 

toward  the  vagina  and  in  exposing  to  the  light  of  day  the  whole 
vagina  and  its  fornices.  Before  Schuchardt  vaginal  incisions 
and  splitting  were  adopted,  but  these  had  no  connection  with 
the  big  paravaginal  incision,  of  about  18  to  20  cm.  length,  which 


1  Karl  Schuchardt,  Concerning  the  Paravaginal  Method  of  Extirpating  tl 
and  Its  Results  in  Cancer  of  the  Uterus.  Arch,  fur  klin.  Chir..  Berlin. 
LXIV,  p.  289. 

18  273 


the  Uterus 
1901,  T. 


274 


HYSTERECTOMY  BY  THE  PAR  A  VAGINAL  ROUTE 


runs  along  all  the  whole  level  of  the  perineum  and  exposes  very 
largely  the  broad  ligament. 

By  this  route  it  is  possible  to  freely  resect  the  vagina  and  the 
parametrium  after  dissection  of  the  ureters.  Adopted  by 
Schauta,1  this  incision  has  been  eulogized  in  America  by  Gell- 
horn,2  in  France  by  Proust,3  and  in  England  by  Sinclair.4 


FIG.  247. — The  circular  vaginal  cuff  has  been  dissected  up,  then  closed,  and  the  sutures 
kept  long.     Also  the  para  vaginal  incision  is  outlined  (Proust). 

Operation. — Schauchardt  makes  an  incision  commencing  at 
the  left  labium  major  and  going  through  the  left  part  of  the 
vaginal  canal.  From  there  the  incision  tends  to  approach  the 
median  line,  while  avoiding  the  rectum  and  sphincter  region. 

1  Schauta,  Monatschrifl  fur  Geb.  und  Gyn.,  1902,  T.  XV,  p.  133,  et  Ibidem,  1904, 
T.   XIX,  p.  475.     See  also  Lehrbuch  der  gesammt.  Gynakologie,   Vienne,   1907,  third 
edition,  T.  II,  p.  444. 

2  George  Gellhorn,  Para  vaginal  Abdominal  Operation  in  Carcinoma  of  the  Uterus. 
Amer.  Jour,  of  Obstetrics,  New  York,  July,  1905,  p.  1. 

3  Proust,  Total  Colpohysterectomy  by  the  Vulvo-perineal  Route.     Presse  medicale, 
Paris,  March  16,  1907. 

*  Sinclair,  On  Paravaginal  Section.     Journal  of  Obst.  and  Gyn.  of  British  Empire, 
London,  April,  1906. 


OPERATION 


275 


Schauta  added  to  it  the  closing  of  the  vagina  in  such  a  manner 
as  to  remove  the  cancer  without  any  fear  of  infection  of  the 
operative  grafts.  Proust,  who  has  published  a  very  good  technic 
of  this  operation,  describes  it  as  follows: 

Circular^  Separation  and  Closing  of  the  Vagina. — After  cau- 


FIG.  248. — The  parayaginal  incision  having  been  made,  a  speculum  is  inserted 
posteriorly.  On  comparing  this  figure  with  247,  one  may  see  the  enlarged  operative 
field  given  by  Schauta's  incision  (Proust). 

terization  of  the  neoplasm  and  disinfection  of  the  vagina,  a  cir- 
cular incision  circumscribing  either  the  middle  portion  or  the 
inferior  portion  of  the  canal  is  done  (Fig.  246).  A  circular  cuff 
of  about  5  cm.  long  having  been  dissected  up,  the  vagina  is 
hermetically  closed  with  sutures,  which  are  kept  long  so  as  to 
serve  as  agents  of  traction. 

When  the  suture  area  has  stopped   bleeding,  the  surgeon 


276 


HYSTERECTOMY    BY   THE   PARA  VAGINAL   ROUTE 


changes  his  gloves  and  instruments  in  order  to  carry  out  the 
antiseptic  stages  of  the  operation. 

Paravaginal  Incision. — The  paravaginal  incision  commences 
more  or  less  high  at  the  level  of  the  inferior  lip  of  the  circular 
incision  of  the  vagina  and  at  the  junction  of  the  posterior  and 
left  lateral  quadrants  and  from  these  it  is  directed  toward  the 
vulva,  which  is  also  cut  through  at  the  junction  of  its  posterior 
and  left  lateral  parts.  Then  it  is  prolonged  directly  backward 


>•': 


FIG.  249. — Liberation  of  the  lateral  borders  of  the  vagina,  attached  by  vascular  pedicles 

(Proust). 

and  laterally,  but  parallel  to  the  axis  of  the  perineum  and  ter- 
minates external  to  the  anus.  It  may  be  carried  on  to  the  sacrum, 
and  become  consequently  pararectal  (Fig.  247). 

The  incision  passes  through  all  the  thickness  of  the  soft 
parts  of  the  perineum;  it  cuts  through  the  tunnel  of  the  levator 
ani  near  the  rectum,  but  spares  the  sphincter  and  the  intestine. 


OPERATION 


277 


The  rectum  is  isolated  and  inclined  toward  the  right.  The 
vessels  are  tied  and  the  wound  tamponed  with  sterilized  gauze. 

In  cases  particularly  difficult  we  may,  after  Staude,  make 
a  double  para  vaginal  incision.1 

Dissection  of  the  Bladder  and  Ureters. — The  separation  of  the 
bladder  is  done  as  in  anterior  colporrhaphy  and  in  tilting  the 
uterus  backward. 

The  separation  becomes  very  simple  when  one  arrives  at  the 


FIG.  250. — The  anterior  peritoneal  cul-de-sac  is  opened  and  the  uterus  tilted  anteriorly: 
the  operator  passes  a  suture  in  order  to  tie  the  round  ligament  (Proust). 

height  of  the  cervix,  in  front  of  which  is  a  lamellar,  cellular 
tissue.  Of  course  if  there  are  neoplasmic  adhesions  at  this  level, 
it  is  a  different  question  and  one  may  be  obliged  in  such  circum- 
stances to  do  a  partial  resection  of  the  bladder. 

Once  the  bladder  is  separated  in  the  median  line,  wre  pass  on 
to  the  isolation  of  its  lateral  angles  "veritable  cornua  which 
continue  with  the  uterus."  Recognizable  by  their  reddish  color, 

1  Staude,  Ueber  totalexstirpation  der  carcinomatosen  Uterus  taittels  doppelseitiger 
Scheidenspaltung.     A/on./.  Geb.  und  Gyn.,  Berlin,  1902,  T.  XV,  p.  863. 


278 


HYSTERECTOMY    BY   THE   PARA  VAGINAL   ROUTE 


they  run  toward  parametrium  and  their  isolation  leads  to  the 
ureter,  which  runs  obliquely  backward  and  outward,  like  a  cord 
running  into  the  base  of  the  broad  ligament.  In  some  cases  one 
has  had  occasion  to  dissect  out  the  ureter  lying  in  a  groove  in 
cancerous  tissue.  In  order  to  follow  the  dissection  of  the  ureters 
sufficiently  far  back,  it  becomes  necessary,  when  their  situation  is 
recognized  and  their  isolation  commenced,  to  free  the  vagina. 
Freeing  of  the  Lateral  Borders  of  the  Vagina  and  Dissection  of 


FIG.  251. — Section  across  the  utero-sacral  ligament  after  tying  it  off  (Proust). 

the  Base  of  the  Parametrium. — One  commences  the  freeing  of  the 
vagina  on  its  posterior  face,  proceeding  in  the  avascular  sepa- 
rable zone  which  results  from  the  coalescence  of  two  fine  layers 
of  the  embryonic  peritoneal  cul-de-sac  and  which  leads  almost 
as  far  as  the  recto-uterine  cul-de-sac  of  the  adult.  The  isolation 
of  the  vagina  only  presents  difficulties  at  its  lateral  borders, 
where  one  finds  the  following  vessels:  the  long  vaginal  branches 
coming  from  the  curve  of  the  uterine  artery,  vaginal  arteries, 


OPERATION 


279 


branches  of  the  hypogastric  artery  and  ramifications  of  the  middle 
hemorrhoidal  and  collateral  vesico- vaginal  veins.  Accom- 
panied by  fibrous  tissue  strands,  these  various  vascular  rami- 
fications constitute  the  principal  means  of  fixation  of  the  vagina, 
the  levators  only  contracting  with  this  canal  during  simple  contact. 
We  must  cut  across  these  and  tie  them  together,  taking  care  to  do 
so  below  the  ureteral  zone  and  not  to  open  the  vagina  (Fig.  249) . 


Fia.  252. — Continuous  suture  of  the  peritoneal  cul-de-sac  (Proust). 

This  freeing  of  the  lateral  borders  of  the  vagina  permits  of  it 
being  drawn  down  and  facilitates  the  access  to  the  parametrium, 
the  methodical  extirpation  of  which  constitutes  one  of  the 
principal  stages  of  the  operation.  Under  visual  control,  dissect 
the  ureter  in  its  latero-cervical  course;  then  tie  the  uterine  artery 
or  wait  until  the  end  of  the  operation. 

Opening  of  the  Peritoneum,  Removal  of  Uterus  and  Vagina.— 


280 


HYSTERECTOMY    BY   THE   PARA  VAGINAL   ROUTE 


Once  the  ureters  are  well  liberated  proceed  to  the  opening  re- 
spectively of  the  anterior  and  posterior  peritoneal  cul-de-sacs. 
This  opening  is  made  with  scissors,  the  fundus  of  the  uterus  is 
tilted  down  and  forward.  Cut  through  and  successively  tie  the 
round  ligament  and  then  the  utero-ovarian  ligament  of  the  same 
side  external  to  the  adnexa  (Fig.  250).  The  broad  ligament  is 
cut  through  in  its  turn  and  the  uterine  artery  is  tied,  if  it  has 


FIG.  253. — Aspect  of  parts  at  the  conclusion  of  the  operation  (Proust). 

not  already  been  done.  Conclude  with  ligature  and  section  of 
the  utero-sacral  ligament  (Fig.  251). 

The  same  manipulation  is  repeated  on  the  opposite  side. 
Thus  we  excise  the  adnexa  en  bloc  with  the  uterus  and  vagina 
closed  and  containing  the  cancer. 

Closing  of  the  Peritoneum.  Reconstruction  of  the  Vulvar 
Ring. — The  peritoneum  is  closed  again  (Fig.  252).  The  two 
anterior  placed  sutures  unite  the  lateral  borders  of  the  remaining 


RESULTS  AND  INDICATIONS  281 

vaginal  cuff  in  such  a  way  as  to  create  a  support  to  the  bladder, 
then  the  vulvo-vaginal  incision  is  closed  up  by  means  of  deep 
sutures,  taking  up  "en  masse"  all  the  tissues.  By  the  vulvar 
orifice  thus  reconstituted  the  gauze  drains  protrude  from  the 
operative  cavity  (Fig.  253). 

Results  and  Indications. — The  results  may  be  viewed  from  the 
standpoint  of  immediate  and  more  remote  results. 

Immediate  Results. — Schuchardt  in  87  cases  had  8  deaths,  or 
9.6  per  cent.  Twice  he  has  had  injury  to  the  bladder,  twice 
injury  to  the  ureter,  and  twice  injury  to  the  rectum.  Schauta1 
in  336  cases  had  36  deaths  from  the  operation,  giving  about 
10.7  per  cent.  In  reality,  the  mortality  is  actually  much  less 
frequent.  In  1907-1908,  it  was  5  in  28  or  17.8  per  cent.;  in 
1908-1909,  it  was  not  more  than  2  in  50,  or  4  per  cent. 

The  operative  complications  have  been  diminishing. 

In  1901-1902,  4  injuries  to  the  ureter  in  47  operations  =  8. 7 
per  cent. 

In  1902-1903,  2  lesions  to  the  ureter  in  29  operations  =  6. 7 
per  cent. 

In  1904-1905-1906,  only  1  lesion  to  the  ureter  in  49  operations 
=2  per  cent. 

In  1907-1908-1909,  0  lesion  in  336  operations,  the  rectum 
4  times. 

Remote  Results. — In  42  cases  which  he  followed  Schuchardt 
found  15  patients  cured  two  years  after  operation,  which  is 
about  35.7  per  cent.;  Schauta  found  36  patients  wrell  after  five 
years,  19  after  four  years,  21  after  three  years,  and  20  after  two 
years. 

1  Schauta,  The  Extended  Results  of  Extirpation  of  the  Cancer  of  the  Cervix  of  the 
Uterus  by  the  Enlarged  Vaginal  Route.     Annales  de  gynecologic,  Paris,  1909,  p.  642. 


CHAPTER  X. 

PERINEAL  AND  SACRAL  ROUTES. 

Summary. — Transverse    and    sagittal    perineotomy. — Operations    by 
the  sacral  route,  parasacral  incision,  resection  of  the  rectum. 

The  perineal  and  sacral  routes  have  been  employed  on  rare  occasions  by 
a  certain  number  of  gynecologists. 

1.  Perineotomy. 

Perineotomy  has  been  practised  by  a  transverse  incision  or  an  antero- 
posterior  incision. 

Transverse  Perineotomy. — In  transverse  perineotomy,  advised  and 
described  by  Otto  Zuckerkandl,  a  flap  in  the  form  of  /  \,  the  figure  is 
traced  on  the  perineum.  The  transverse  portion  of  the  incision  measures 
7  cm.  and  lies  about  3  cm.  in  front  of  the  anal  orifice;  the  two  divergent  sides 
are  directed  toward  the  ischia;  in  deepening  this  incision  one  arrived  to 
penetrate  the  recto-vaginal  space  almost  to  the  recto-uterine  cul-de-sac. 

Operation. — After  incising  the  skin  and  superficial  fascia,  separate  up  the 
flap,  and  cut  through  the  fibers  of  the  external  sphincter  which  go  toward  the 
f ourchette  and  then  separate  the  rectum  from  the  vagina  up  the  whole  length 
of  the  sphincter.  Then  cut  across  the  fibers  of  the  recto-vaginal  muscle, 
some  fibers  of  the  levator,  and  one  finds  oneself  in  the  easily  separable  space 
intermediate  between  the  vagina  and  rectum,  from  whence  one  may  easily 
make  way  as  far  as  the  peritoneal  cul-de-sac.  It  is  sufficient  to  press  the 
rectum  backward  in  order  to  have  a  fully  exposed,  widely  opened  wound, 
whose  base  reaches  to  the  peritoneal  cul-de-sac.  This  wound  is  limited 
behind  by  the  rectum,  in  front  by  the  posterior  face  of  the  vagina  and  later- 
ally by  the  ischia,  which  are  covered  by  the  fatty  tissue  of  the  ischiorectal 
fossa. 

The  peritoneum  being  opened  transversely,  introduce  the  hand,  tilt  into 
the  wound,  the  uterus  and  adnexa,  ligature  and  cut  across  the  broad  liga- 
ments, open  through  the  vesico-uterine  peritoneum  anteriorly,  separate  off 
the  bladder  and  excise  the  uterus. 

This  operation  has  been  used  in  opening  certain  pelvic  abscesses  in  order 
to  remove  vaginal  neoplasms  and  to  excise  advanced  uterine  cancers. 

282 


SACRAL  ROUTE 


283 


Sagittal  Perineotomy. — In  sagittal  perineotomy,  more  often  called 
vertical  perineotomy,  the  incision  is  usually  anteroposterior.  Siinger, l  who 
has  had  most  frequent  recourse  to  it,  makes  an  incision  to  the  side  of  the 
median  line — commencing  at  the  level  of  the  posterior  third  of  the  labium 
major  and  terminating  2  cm.  external  to  the  anal  orifice  between  this  orifice 
and  the  ischiahtuberosity.  He  cuts  across  the  levators. 

2.  Sacral  Route. 

The  incision  may  be  simply  parallel  to  the  sacrum  when  it  is  called  the 
parasacral  route;  it  may  accompany  a  more  or  less  extensive  resection  of  the 
sacrum;  it  is  then  properly  speaking  the  sacral  route.2 


FIG.  254. — Transverse  perineotomy.          FIG.  255. — Sagittal  perineotomy. 

Parasacral  Route. — This  may  be  various. 

E.  Zuckerkandl  makes  an  incision  parallel  to  the  border  of  the  sacrum, 
extending  from  the  postero-inferior  iliac  spine  to  the  ischiorectal  fossa  at 
equal  distance  from  the  tuberosity  and  the  rectum;  he  cuts  through  the  mus- 
cles and  the  ligaments  without  fear  of  injuring  the  vessels  and  nerves  of  the 
sciatic  foramen,  which  lie  externally. 

Wolffer  makes  an  incision  which  commences  about  1  or  2  cm.  external 
to  the  incision  of  the  coccyx  and  sacrum;  this  incision,  like  an  arc  of  a  circle, 
passes  near  the  rectum  and  terminates  in  the  perineum  about  2  or  3  cm.  from 
the  inferior  commissure  of  the  vulva.  He  incises  the  gluteus  maximus,  the 

1  Sanger,  Archiv  f.  Gyn.,  Berlin,  1890,  T.  XXXVII,  p.  100. 

2  Terrier  and  Hartmann,  Annales  de  gyn.,  Paris,  1891,  T.  II,  p.  81. 


284 


PERINEAL   AND   SACRAL    ROUTES 


sciatic  ligaments,  large  and  small,  near  their  insertion,  and  then  the  levator 
ani,  after  which  he  separates  the  rectum  from  the  vagina. 

Sacral  Route. — In  the  sacral  route  the  osseous  resection  may  be  more 
or  less  extensive;  Kraske  resects  the  coccyx  and  the  left  portion  of  the  sacrum, 
following  a  line  the  horizontal  part  of  which  passes  below  the  third  sacral 


FIG.  256.— Kraske. 


FIG.  257. — Roux. 


foramen ;  Roux  makes  a  transverse  incision  below  the  third  sacral  foramen ; 
Hochenegg  makes  a  resection  intermediate  in  some  respects  to  the  other  two, 
taking  care  to  include  the  nerves  proceeding  from  the  right  fourth  sacral  fora- 
men and  the  right  sacrosciatic  ligaments. 

Others  have  done  temporary  resections,  cutting  transversely  across  the 


FIG.  258. — Hochenegg. 

sacrum  below  the  third  sacral  foramen,  after  folio  wing  its  right  border  (Roux),. 
or  making  an  oblique  section  which  passes  to  the  right  between  the  third  and 
fourth  sacral  foramen,  to  the  left,  through  the  lateral  portion  of  the  cornu. 
(Hegar  and  Wiedow). 


SACRAL  ROUTE  285 

The  important  point  is  to  get  good  exposure  of  the  parts;  the  opening 
of  the  sacral  canal  is  of  no  importance  because  the  dura  mater  is  not  diseased, 
and  it  eventually  forms  a  fibrous  and  resistant  cicatrix. 

These  operations  by  the  sacral  route  have  to-day  been  almost  abandoned; 
they  present  certain  difficulties  and  are  exposed  to  complications.  Some- 
times there  is  trouble  to  recognize  and  open  the  peritoneum;  the  intestine, 
bladder  and  ureter  have  all  been  injured.  An  interesting  point  to  note  is 
that  the  injured  ureter  is  always  on  the  operated  side,  which  is  explained 
by  the  fact  that  it  separates  easily  from  its  cellular  connections  with  the 
pelvic  wall  and  that,  being  very  mobile,  it  is  easily  drawn  upon  and  injured. 


PART  III. 
OPERATIONS  BY  THE  ABDOMINAL  ROUTE. 

CHAPTER  I. 

SHORTENING  OF  THE  ROUND  LIGAMENTS  IN  THE  INGUINAL 

REGION. 

Summary. — Anatomical  Survey. — Operative  Technic. — Results  and  In- 
dications. 

The  shortening  in  the  inguinal  region  of  the  round  ligaments 
was  advocated  by  Alquie  in  1840,  but  his  work  had  fallen  into 
oblivjon  when  Alexander  in  1881  did  it  and  Adams  in  1882 
helped  to  familiarize  it. 

Commonly  described  as  Alexander's  operation,  the  shortening 
of  the  round  ligaments  is  sometimes  known  under  the  name  of 
the  Alquie-Alexander-Adams  operation. 

Anatomical  Recapitulation. — The  round  ligament,  commenc- 
ing at  the  cornu  of  the  uterus,  lifts  up  the  anterior  fold  of  the 
broad  ligament  and  runs  down  the  inguinal  canal,  where  the 
cord  breaks  up  into  a  series  of  fibers  which  separate  to  become 
inserted  into  the  connective  tissue  and  skin  of  the  mons  veneris, 
the  pillars  of  the  inguinal  canal,  to  the  periosteum  and  spine  of 
the  pubis. 

In  its  inguinal  course,  the  round  ligament  is  a  veritable  cord 
which  is  sometimes  accompanied  by  a  diverticulum  of  the  peri- 
toneum (canal  of  Nuck)  situated  internal  to  it. 

The  round  ligament,  the  peritoneal  diverticulum  when  it 
exists,  and  numerous  veins  are  united  by  cellular  tissue  into  a 
cord,  which  crosses  posteriorly,  superiorly  and  external  to  the 
epigastric  vessels.  Above  it  lies  the  inferior  abdomino-genital 
nerve. 

At  the  level  of  the  external  inguinal  ring  the  terminal  fibrils 
of  the  round  ligament  are  in  a  great  measure  included  in  the 

286 


OPERATIVE  TECHNIC 


287 


pad  of  fat,  Imlach's  pad,  which  enters  the  canal  as  a  fatty 
cord. 

Operative  Technic. — The  round  ligament  ramifies  at  the  level 
of  the  pad  of  fat,  which  covers  the  external  inguinal  ring  and 
we  must  therefore  search  for  it  in  the  inguinal  canal,  where  it  is 
still  a  round  cord. 

The  first  stage  of  the  operation  consists  in  exposing  the 
inguinal  canal.  To  do  that  make  an  incision  of  7  to  8  cm. 


FIG.  259. — External  orifice  of  the  inguinal  canal. 

long,  commencing  at  the  spine  of  the  pubis,  parallel  to  the 
crural  arch,  an  incision  which  generally  is  concealed  by  the 
pubic  hair. 

In  order  to  be  sure  of  not  mistaking  the  fascia  transversalis  for 
the  aponeurosis  of  the  external  oblique,  which  may  be  the  case 
with  fat  women,  it  is  advisable  to  deepen  the  incision  externally  to 
a  point  where  one  is  certain  to  meet  \vith  the  solid  and  resistant 
plane  of  the  pearly  external  oblique.  Where  this  is  fully  ex- 
posed run  a  grooved  director  along  it  from  above  downward  and 


288 


SHORTENING   OF   THE    ROUND   LIGAMENTS 


from  without  in,  which  necessarily  leads  us  to  the  external  rings, 
always  easily  recognized  in  this  way.  We  can  see  the  internal 
and  external  pillars,  the  round  ligament  and  nerves  issuing  from 
the  ring. 

The  canal  is  opened  on  the  grooved  director  for  a  length  of 
about  4  cm. ;  then  drawing  back,  if  necessary,  the  interior  border 
of  the  internal  oblique  with  a  retractor,  one  exposes  the  round 
ligament.  Even  when  it  is  atrophied  in  its  superficial  layers,  it 


FIG.  260. — External  ring  of  inguinal  canal. 

always  appears  on  looking  deeper  as  a  bluish  colored  cord, 
reddened  in  part  by  the  vessels.  When  recognized  it  is  isolated, 
and  with  the  director  we  tear  through  the  fibrous  tracts  which 
unite  it  to  the  walls  of  the  canal.  Press  back  with  gauze  the 
peritoneum  which  envelops  it.  By  gentle  and  [continuous  trac- 
tion it  may  be  gradually  brought  out,  until  it  may  be  freed  for 
about  10  or  12  cm.  Now  the  separation  of  the  peritoneum  be- 
comes more  difficult,  as  the  uterine  cornu  rests  against  the  deep 


OPERATIVE   TECHXIC 


289 


face  of  the  wall  and  opposes  resistance  to  the  traction.  It 
happens  often  during  these  manipulations  that  the  abdomen  is 
opened,  not  that  this  is  of  such  importance,  but  it  is  even  of  ad- 
vantage to  systematically  open  the  peritoneum  in  such  a  way  as 
to  be  able  to  explore  with  the  finger  the  corresponding  adnexa 
and  to  liberate,  if  necessary,  any  adhesions  that  exist.  The  im- 
portant point  is  always  to  act  with  gentleness  in  such  a  manner 
as  to  avoid  rupturing  the  ligament. 


FIG.  261. — The  round  ligament  is  freed  from  the  peritoneum,  the  cul-de-sac  of  which 
may  be  seen  immediately  below  the  retractor. 

The  canal  is  closed  as  in  Bassini's  operation,  suturing  the 
peritoneum,  uniting  the  internal  oblique  and  the  transversalis  to 
Poupart's  ligament,  taking  care  to  include  the  round  ligament  in 
the  two  or  three  inferior  sutures  (Fig.  262).  Conclude  the 
fixation  by  uniting  the  ligament  to  the  superficial  portion  of  the 
aponeurosis.  The  terminal  part  of  the  round  ligament  is  then 
resected. 


19 


290 


SHORTENING   OF   THE    ROUND   LIGAMENTS 


The  aponeurosis  of  the  external  oblique  and  then  the  skin 
are  sutured  without  drainage. 

The  same  manipulations  are  carried  out  on  the  opposite  side ; 
the  operation  is  concluded  by  the  application  of  a  vaginal  tampon 
or  by  that  of  a  pessary,  which  is  destined  to  prevent  the  uterus 
from  exercising  the  traction  of  its  weight  on  the  fixation  sutures 
of  the  ligament  for  the  first  few  days. 

Various  modifications  have  been  added  to  the  type  of  operation  we  have 
just  described.     In  place  of  making  two  symmetrical  incisions  some  operators 


FIG.  262. 


make  a  single  curved  incision  to  it,  the  convexity  on  a  level  with  the  pubis 
(Bumm,1  Flaischlen2)  and  others  close  the  canal  by  making  use  of  the  round 
ligament  through  which  the  sutures  pass  in  a  spiral  form  in  traversing  from 
one  wall  to  the  other  (Abbe3),  in  splitting  it  and  threading  each  of  its  halves 
through  one  of  the  lips  of  the  incised  canal  and  then  tying  them  together 

1  Bumm,  in  N.  Staedler,  Arch,  fur  Gyn.,  Berlin,  1899,  T.  LVIII,  p.  492. 

2  Flaischen,  Monatschr.f.  Geb.  und  Gyn.,  Berlin,  1899,  T.  IX,  p.  26,  and  T.  XI,  p.  309. 

3  Robert  Abbe,  Fixation  of  the  Round  Ligament  in  Alexander's  Operation.     Annals 
of  Surg.,  Philad.,  December,  1896,  p.  699. 


OPERATIVE  TECHNIC  291 

( Juvara1).  Others  bend  the  round  ligament  upward  and  out. ward  and  fix  it  to 
the  external  face  of  the  aponeurosis  of  the  external  oblique  in  the  direction  of 
the  anterior  superior  spine  (Kocher2),  while  others  unite  the  extremities  of 
the  resected  round  ligaments  together  (Doleris3).  Bourcart,  after  drawing 
strongly  on  the  round  ligament,  incises  the  peritoneum  immediately  external 
to  it:  the  traction  on  the  round  ligaments  draws  the  uterus  forward;  those  on 
the  cone  of  peritoneum  act  on  the  adnexa.  In  this  way  we  can  graduate  the 
action  on  the  uterus  and  ovary  as  we  wish,  fixing  the  round  ligament  to  the 
aponeurosis  and  then  closing  the  peritoneum  in  suturing  the  external  cone 
to  the  round  ligament  more  or  less  distant  from  the  uterus  as  there  is  neces- 
sity for  drawing  the  adnexa  forward.4 

Results  and  Indications. — The  immediate  results  are  good. 
There  is  no  trouble  in  connection  with  the  bladder.  The  remote 
results  should  be  viewed  from  a  triple  standpoint,  viz.,  ortho- 
pedic, therapeutic  and  obstetric.  From  the  orthopedic  point  of 
view,  if  one  has  been  careful  to  secure  a  forced  antedeviation  the 
cornua  are  in  contact  with  the  abdominal  walls  and  the  results 
are  generally  good;  it  is  rare  to  find  recurrences  in  cases  of 
retro-uterine  adhesions  or  when  the  operation  has  been  used 
for  prolapse. 

From  the  therapeutic  aspect,  pains  only  occur  when  coin- 
cident with  the  deviation  that  are  inflammatory  lesions,  in  par- 
ticular those  of  the  adnexa.  It  has  been  demonstrated  that  a 
consecutive  hernia  is  rare  if  the  walls  have  been  well  sutured. 

From  succeeding  pregnancies,  inguinal  shortening  of  the 
ligaments  seems  to  exert  no  bad  influence. 

The  examination  of  immediate  and  remote  effects  leads  us  to 
the  conclusion  that  the  operation  is  indicated  in  simple  retro- 
deviations  and  prolapse;  if  in  the  latter  case,  it  is  combined  with 
a  plastic  vagino-perineal  repair.  It  ought  only  to  be  done, 
however,  during  active  sexual  life  when  the  ligaments  are  well 
developed  and  capable  of  supporting  the  weight  of  the  uterus. 

In  practice  we  do  not  perform  this  operation  much: 

1.  Because,  while  it  gives  good  results,  it  is  necessary  that 
there  be  no  retro-uterine  adhesions  nor  inflammatory  lesions  of 

1  Juvara,  Presse  midicale,  Paris,  1901,  p.  178. 

2  Kocher,  Chir.  Operationslehre  et  in  Lanz,  Arch,  fur  Gyn.,  Berlin,  1893,  T.  XLIV, 
p.  348. 

3  Doleris,  Nouvelles  Archiv  d'obstetrique  et  de  gyn.,  February,  1889,  p.  49. 
*  Bourcart,  Ann.  de  gyn.,  Paris,  1907,  p.  705. 


292  SHORTENING   OP  THE    ROUND   LIGAMENTS 

the  uterus  or  adnexa;  that  in  all  such  cases,  retrodeviations 
which  present  no  painful  symptom  may  most  often  be  left  to 
themselves. 

2.  Because    we   possess  to-day,  as  will  be  seen  later,  most 
excellent  means  of  fixing  the  uterus  in  good  position. 


CHAPTER  II. 

ABDOMINAL  CELIOTOMY. 

Summary. — General  technic. — Operative  precautions  (operator,  sur- 
roundings, operated). — Median  celiotomy  (ineision,  limitation  of  operative 
field,  treatment  of  adhesions,  hemostasis,  peritonization,  examination  of  the 
appendix,  closing  of  the  wall,  drainage). — Transverse  celiotomy. — Post- 
operative precautions. — Complications  (shock,  hemorrhage,  peritonitis, 
intestinal  occlusion,  pulmonary  complications,  parietal  suppuration,  fistula, 
phlebitis  eventration). 

Under  the  name  of  celiotomy  is  meant  the  opening  of  the 
peritoneal  cavity  or  celom.  The  means  of  access  to  the  cavity 
are  multiple.  We  have  already  described  its  opening  under  the 
name  of  vaginal  celiotomy  or,  more  correctly,  colpo-celiotomy . 
Most  often  the  entrance  into  the  abdomen  is  through  the  abdomi- 
nal walls;  it  is  abdominal  celiotomy. 

This  term,  abdominal  celiotomy,  tends  to  replace  the  incorrect 
form  laparotomy  which  means,  literally,  lateral  incision.  The 
word  laparotomy  should  be  rejected  as  also  that  of  gastrotomy 
which  wras  generally  employed  at  one  time  and  is  now  reserved 
to  the  opening  of  the  stomach. 

1.  General  Technic  of  Abdominal  Celiotomy. 

It  was  once  regarded  as  a  very  serious  operation.  The 
patients  died  of  hemorrhage  or  suppuration  and  the  rare  cures 
were  considered  as  happy  chances.  Actually,  the  opening  of 
the  peritoneal  cavity,  executed  according  to  rules  and  by  a 
surgeon  knowing  his  work,  presents  no  longer  any  danger. 
This  is  due  to  the  introduction  into  surgical  technic  of  antisepsis 
and  asepsis. 

It  is  important  to  draw  attention  to  the  employ  of  purely 
aseptic  methods. in  abdominal  surgery.  From  the  time  that  the 
peritoneum  is  opened*  leave  all  antiseptics  on  one  side  and  only 
employ  asepsis. 

293 


294  ABDOMINAL   CELIOTOMY 

The  action  of  antiseptics  on  pathogenic  organisms  is  largely 
counterbalanced  by  .injurious  effects  to  peritoneal  endothelium. 
This  destruction  of  peritoneal  endothelium,  as  the  laboratory 
experiments  of  our  colleague  Delbet  proved,  confirm  our  clinical 
results  and  leave  no  doubt  of  the  disastrous  consequences  that 
may  be  occasioned. 

Certainly  absolute  asepsis  is  never  realized  whatever  precau- 
tions are  taken.  It  is  not  indispensable;  one  should  endeavor 
to  obtain  it  as  completely  as  possible,  but  happily  one  finds  in 
the  body  elements  capable  of  resisting  a  microbic  invasion  of 
the  operative  field.  The  peritoneum  possesses  a  considerable 
resistance  as  our  clinical  observation  has  established.  It  is  not 
rare  to  observe  patients  get  better  without  the  least  peritoneal 
reaction  although  they  present  a  parietal  suppuration  some  days 
or  weeks  after  the  operation.  But,  in  order  that  the  struggle 
may  be  efficacious,  it  is  necessary  that  the  tissues  preserve  all 
the  phagocytic  action  which  a  strong  antiseptic  may  impair. 

The  employ  of  antiseptics  has  other  drawbacks  which, 
although  not  immediate,  are  none  the  less  important.  We 
refer  to  extensive  adhesions,  produced  by  the  irritation  of  the 
serous  membrane.  The  production  of  these  adhesions  has  so 
many  drawbacks  that  it  is  sufficient  alone  to  withhold  their  use 
in  abdominal  surgery. 

In  another  sense,  the  more  recent  technical  improvements  have 
contributed  to  reduce  the  risks  of  celiotomy. 

These  chief  improvements  are  three  in  number:  limitation  of 
the  operative  field,  the  suppression  of  large  pedicles  and  the 
doing  away  with  intraperitoneal  surfaces. 

The  limitation  of  the  operative  field,  as  far  as  one  is  able* 
results  in  the  reduction  in  size  of  a  possible  infected  zone  and 
renders  the  operation  extraperitoneal  as  it  possibly  can  be. 
The  following  result  is  thus  obtained : 

1.  By  the  use  of  the  inclined  plane. 

2.  By   the   methodical   isolation   of   the   pelvic   cavity   with 
sterilized  compresses. 

While  Scultet  used  the  elevated  pelvis  position,  with  an 
inclined  plane,  it  is  to  Trendelenburg  that  the  merit  is  due  of 
using  the  inclined  plane  in  order  to  favor  descent  of  the  intestine 
in  all  operations  on  the  pelvic  cavity. 


GENERAL  TECHNIC  OF  ABDOMINAL  CELIOTOMY  295 

Since  1890  I  have,  in  Paris,  constantly  used  the  inclined 
plane,  and  at  the  same  time  my  friend  Delageniere  used  it  at 
Mans ;  at  present  its  employ  is  general. 

In  this  elevated  pelvis  position,  with  the  body  at  an  angle  of 
45  degrees,  J;he  intestines  fall  toward  the  diaphragm  and  leave 
the  operative  field  free.  This  intervention  renders  the  operation 
easier  and  safer.  It  has  been  said  that  it  may  lead  to  pulmonary 
or  cephalic  congestion.  In  some  stout  women,  with  fatigued 
hearts,  there  is  at  first  some  facial  cyanosis,  but  it  is  very  excep- 
tional to  find  that  this  extends  to  a  degree  involving  the  return 
to  the  horizontal  position. 

The  employ  of  aseptic  cloths  which  our  master  Ferrier  made 
common  is  the  natural  complement  of  the  inclined  plane.  By 
placing  them  methodically,  one  may  completely  isolate  the 
pelvic  from  the  rest  of  the  abdominal  cavity  and  thus  the  risk  of 
infecting  the  general  peritoneal  cavity  is  reduced  to  a  minimum. 
For  this  purpose  a  good  anesthesia  with  calm  and  regular  respira- 
tion permits  of  the  constant  and  regular  maintenance  of  the 
compresses  below  the  intestines  and  constitutes  a  considerable 
operative  adjuvant.  Personally,  I  consider  that  a  good  anes- 
thesia is  more  important  than  a  good  assistant. 

The  suppression  of  large  pedicles  constitutes  an  improvement 
none  the  less  important.  The  ligature  en  masse  of  pedicles, 
formerly  the  custom,  presents  numerous  drawbacks.  It  is 
complicated,  dangerous  and  generally  useless.  To  show  how 
complicated  it  is,  one  has  only  to  think  of  the  numerous  ligatures 
devised  to  accomplish  it  (chain  ligature,  Tait's  knot,  Bantock's 
knot,  etc.).  Its  danger  is  emphasized  by  the  way  it  slips  when 
most  carefully  applied;  most  dangerous  hemorrhages  of  course 
result  from  this  when  the  abdomen  is  closed ;  useless  also  because 
these  large  pedicles  are  often  avascular  along  the  greater  course 
of  their  length.  Thus  when  one  proceeds  to  the  removal  of  the 
adnexa,  two  small  ligatures,  one  placed  externally  on  the  utero- 
ovarian  artery  and  the  other  internally  on  the  uterine  artery 
suffice  to  secure  the  hemostasis.  In  these  conditions  why  is  it 
necessary  to  tie  an  enormous  ligature  around  the  upper  part  of 
the  broad  ligament  ?  That  is  not  all.  In  addition  to  these 
immediate  drawbacks  the  large  pedicles  have  even  more  remote 
results.  They  present  a  large  raw  surface  ready  to  contract 


296  ABDOMINAL   CELIOTOMY 

adhesions.  Every  surgeon  has  seen  those  sad  cases  where  a 
bilateral  excision  of  the  adnexa  left  two  large  more  or  less  in- 
fected pedicles,  as  painful  as  the  organs  removed. 

The  suppression  of  the  rawed  intraperitoneal  surface  con- 
stitutes another  improvement.  The  reconstitution  of  the  perit- 
oneum over  the  raw  surface  and  ligatures,  commonly  known 
in  France  as  "peritonization,"  has  the  advantage  of  preventing 
these  raw  surfaces  from  exuding  their  products  into  the  perit- 
oneal cavity.  It  is  also  sufficient  to  prevent  the  secondary 
formation  of  adhesions,  a  source  of  pain  and  such  grave  com- 
plications as  intestinal  occlusion. 

2.  Preparatory  Measures. 

We  will  consider  this  under  three  heads:  the  operator,  the 
patient,  and  the  surroundings.1 

Operator. — The  surgeon  who  undertakes  a  celiotomy  should 
be  quite  well;  a  good  physical  state  assures  the  operator  that 
moral  condition  which  enables  him  to  form  and  execute  decisions 
rapidly  and  well.  He,  his  assistants,  and  his  material  should 
be  aseptic. 

We  will  not  go  into  the  means  of  securing  this  state  of  affairs. 
Rubber  gloves  should  always  be  employed.  They  should  be 
used  in  all  abdominal  operations.  Masks,  however,  if  the 
operator  does  not  speak,  appear  to  us  to  be  useless.  Personally 
we  only  use  them  when  we  have  coryza  or  sore  throat. 

Surroundings. — -The  surroundings  are  not  of  such  great 
importance  as  one  would  be  led  to  believe  a  priori.  It  is,  how- 
ever, prudent  to  avoid  operating  septic  cases  in  the  same  theater 
as  one  does  celiotomies.  It  is  advisable  to  give  any  spectators 
aseptic  blouses,  to  caution  them  not  to  touch  anything,  not  to 
crane  over  the  operative  field  and  not  to  breathe  on  the  wound. 

Patient.- — It  is  the  patient  who  is  above  all  the  object  of  the 
preparatory  attentions.  It  is  essential,  when  there  is  no  absolute 
urgency,  to  prepare  her  at  the  operation. 

1 .  To  increase  her  resistance  as  much  as  possible  to  infection 
and  to  stimulate  the  function  of  her  in  such  a  manner  as  to 

1  See  the  discussion,  French  Congress  of  Surgery,  1909,  and  Holybach,  Einige  Bemerk. 
uber  Vor  und  Nachbehand.  gynec.  Op.s  Samml.  klin.  Vortr.,  1910. 


PREPARATORY  MEASURES  297 

obtain  an  easy  elimination  of  toxic  substances  in  cases  where  an 
infection  may  be  brought  about. 

2.  To  render  her  skin  aseptic. 

1.  Preparation  of  the  Patient. — In  order  to  place  her  in  the 
best  possible  conditions  of  resistance,  we  should  insist  before 
the  operation  a  moral  and  physical  repose  of  some  days,  giving 
hypnotics  if  necessary  to  the  neurotic  subjects.  We  think  it 
is  as  well  not  to  state  beforehand  the  day  of  the  operation  in 
order  to  avoid  apprehension,  sleepless  nights,  and  the  state  of 
terror  which  sometimes  gives  rise  to  complications  at  the  com- 
mencement of  anesthesia.  If  the  patient  is  a  little  agitated,  we 
give  a  sedative  before  the  day  of  operation  in  order  to  secure  a 
good  calm  night. 

The  regime  is  nothing  special.  Avoid  objects  difficult  of 
digestion.  In  patients  with  glycosuria,  albuminuria  and  some- 
times stout  subjects,  a  special  regime  is  to  be  recommended. 

In  a  general  manner  of  speaking  avoid  all  operation  in 
diabetic  subjects,  above  all  in  those  with  polyuria  and  flabby  skin ; 
on  the  contrary,  the  simple  presence  of  a  moderate  quantity  of 
sugar,  combined  writh  a  good  general  state,  does  not  contraindi- 
cate  an  operation.  However,  it  is  advisable  before  operating  to 
give  a  regime  of  milk  and  alkalies  to  reduce  the  sugar.1 

Albuminuria,  wrhich  many  gynecologists  think  is  a  contra- 
indication to  any  operation,  certainly  is  an  unfavorable  symp- 
tom. It  is  none  the  less  true  that  in  certain  conditions,  such  as 
uterine  fibroids  where  it  results  from  the  interference  of  the 
sexual  function  by  the  pelvic  tumor,  the  operation  is  absolutely 
indicated.  In  such  cases  we  operate  after  giving  them  a  course 
of  fifteen  days  on  milk.  We  are  doubtful  of  cases  where  in  addi- 
tion to  albuminuria  there  are  also  epithelial  cylinders  in  the  urine. 

In  stout  subjects  the  celiotomies  are  more  difficult,  longer, 
and  more  dangerous.  It  is  a  question  when  there  is  nothing 
urgent  whether  a  course  should  not  be  suggested  enabling 
the  patient  to  become  thinner.  Pauchet  advises  a  regime  in 
which  the  essentials  are  vegetable  soups,  green  vegetables,  fruits, 
oranges,  with  water  as  beverage.  Others  recommend  a  milk 
diet,  consisting  of  2  1/2  liters  per  diem. 

1  Some  authors  have  blamed  chloroform  as  the  cause  of  diabetic  coma;  in  reality 
the  question  of  anesthesia  is  secondary.  Coma  has  come  on  after  simple  spinal  anes- 
thesia (Flith,  Holzbach). 


298  ABDOMINAL  CELIOTOMY 

When  the  patients  are  run  down  and  enfeebled,  among  those 
who  have  worked  up  to  the  last  minute  and  arrive  at  the  hospital 
quite  exhausted,  it  is  advisable  to  recommend  some  days  of  rest,  to 
give  baths,  a  fortifying  diet,  tonics  to  stimulate  the  excretions,  and 
even  if  the  heart  is  feeble  to  give  a  little  digitalis  or  strychnine. 

We  attach  a  great  importance  to  the  careful  cleaning  of  the 
mouth.  We  may  thus  diminish  the  occurrence  of  pulmonary 
complications  of  postoperative  parotitis,  etc.  Remove  the 
tartar  and  then  brush  the  teeth  well,  etc. 

The  evacuation  of  the  intestine  by  purgatives,  besides  being 
the  best  of  disinfectants,  has  the  advantage  of  cleaning  the 
digestive  tube  of  its  contents,  liquid  or  gaseous,  wrhich  reduces 
the  volume  of  the  intestine  and  facilitates  the  intraabdominal 
manipulations.  It  is  advisable  not  to  give  too  much  purgation 
and  to  avoid  drastic  purgatives.  We  give  an  oily  or  saline  laxa- 
tive two  days  before  the  operation  and  an  enema  or  laxative 
the  day  before  the  operation  if  the  primary  result  has  been 
unsatisfactory.  We  may  thus  be  certain  of  avoiding  the  dis- 
advantages consequent  upon  the  continuation  of  purgation  on 
the  morning  of  the  operation.  Never  give  violent  purgatives 
as  the  fatigue  of  the  muscular  intestinal  \vall  helps  to  augment 
the  postoperative  bowel  paresis  at  times  when  it  is  necessary 
to  induce  contractions  of  the  bowel  for  the  discharge  of  pus. 

2.  Disinfection  of  the  Operative  Region. — The  day  before  the 
operation  the  skin  is  shaved.  The  patient  is  then  cleaned  up 
with  soap  and  water  in  such  a  manner  as  to  stimulate  the  skin 
functions.  Be  particular  to  remove  epidermic  debris. 

The  vagina  is  disinfected  with  repeated  antiseptic  irrigations 
and  even  most  carefully  bathed  with  soap  and  water  on  the 
morning  of  the  operation  and  then  packed  with  iodoform 
gauze. 

Latterly  surgeons  have  endeavored  by  ante-operative  meas- 
ures to  combat  the  hemorrhages,  intravenous  coagulations,  and 
infections,  secondary  to  intervention. 

They  set  to  work  by  ascertaining  the  coagulability  of  the 
blood,  and  if  it  is  not  normal,  endeavoring  to  obtain  that  state 
by  the  administration  of  calcium  salts,  subcutaneous  injections 
of  gelatine  5  to  100,  animal  serum  and  milk  diet,  or  anti-coagu- 
lants (citric  acid,  potassium  citrate,  vegetarian  diet,  Prussian 


OPERATION  299 

blue  injected  intravenously)  and  to  thus  prevent  the  occurrence  of 
hemorrhages  or  that  of  thrombosis  or  embolus  (Wright) . 

Others  propose  to  immunize  the  patient  against  surgical 
infection  by  a  streptococcal,  staphylococcal  or  colibacillary  vacci- 
nation. Unhappily,  there  is  yet  no  serum  which  prevents  the 
development  of  infection  in  man.  It  has  been  suggested  to 
increase  the  resistance  to  infection  by  making  a  pre-operative 
leucocytosis.  The  subcutaneous  injection  of  20  c.c.  of  a  solution 
of  1  per  cent,  nucleinate  of  soda  has  been  recently  declared  as 
valueless  (Aschner  and  Von  Graff) . 

Personally  we  have  never  used  any  of  these  plans,  and  their 
efficaciousness  appears  to  us  to  be  incompletely  established. 
On  the  contrary,  when  the  patient  is  feeble,  we  do  not  hesitate  to 
give  her,  the  day  before  and  the  morning  of  the  operation,  a 
subcutaneous  injection  of  3  to  500  c.c.  of  physiological  serum. 

Urgency  Operation. — In  case  of  urgency  it  is  evident  that 
preparatory  treatment  should  be  reduced  to  a  minimum.  Be 
content  to  stimulate  the  patient  with  subcutaneous  injections 
of  normal  saline  or  in  extreme  anaemia  \vith  intravenous  ones. 
Also,  give  injections  of  strychnine  and  disinfect  the  skin  with 
two  applications  of  tincture  of  iodine  at  some  minutes  interval 
(Grossich) . 

3.  Operation. 

The  opening  of  the  abdomen  is  generally  carried  out  in  the 
median  line;  some  operators  prefer  the  median  vertical  incision 
to  the  transverse  suprapubic  one  and  differentiate  them  by  the 
names  of  median  and  transverse  celiotomies. 

A.  Median  Celiotomy. 

Preliminaries  of  the  Operation. — The  surgeon  and  his  assist- 
ants after  having  disinfected  their  hands  in  the  usual  wray  and 
put  on  rubber  gloves,  and  then  placed  in  large  receptacles  the 
necessary  armament  for  the  operation:  large  cloth  dressings, 
sterilized  gauze  with  which  to  sponge,  simple  or  chromicized 
catgut,  silkworm-gut  sutures,  the  usual  abdominal  instruments 
and  very  few  special  ones,  wire  metal  retractors,  a  large  valvular 


300  ABDOMINAL   CELIOTOMY 

retractor  the  fixed  point  of  which  lies  between  the  legs,  a  blunt 
needle  to  tie  vessels,  some  tampon  holders,  and  some  large  and 
small  Museux's  forceps.  The  needles  to  be  used  for  the  sutures 
are  sharpened  before  and  kept  between  sterilized  compresses. 

During  these  preparations,  the  patient  is  anesthetized  in  her 
bed  or  in  an  adjoining  room.  The  bladder  is  emptied.  We 
use  chloroform  usually  because  the  respiration  is  calmer  than 
that  induced  by  ether  and  in  not  producing  any  cephalic  con- 
gestion proves  its  superiority  in  this  respect  for  operations  in  the 
inclined  plane,  as  is  so  constantly  done  to-day. 


FIG.  263. — Large  valvular  retractor  with  its  fixed  point  placed  between  the  legs  (Doyen). 

When  the  anesthesia  is  sufficiently  complete  to  enable  the 
patient  to  be  transported,  she  is  brought  into  the  operation 
theater  and  placed  on  the  table  which  is  provided  with  shoulder 
pieces  so  that  when  her  legs  are  fixed  in  the  elevated  position  and 
table  head  lowered,  she  will  not  be  suspended  by  the  knees. 
The  arms  lie  alongside  the  body  and  are  tied  with  a  serviette  or 
bandage.  Never  place  them  as  one  often  sees  in  forced  abduction 
as  this  exposes  them  to  paralysis  of  the  roots  of  the  brachial 
plexus,  which,  although  spontaneously  capable  of  cure,  neverthe- 
less causes  the  patient  much  worry. 

A  \varm  application  is  applied  over  the  chest,  a  second  is  in- 
sinuated under  the  kidneys. 

A  fresh   abdominal   toilet  is  made  by  an  assistant.     Brush 


OPERATION  301 

well  with  soap  and  water,1  ether,  alcohol  and  1  to  1000  sublim- 
ate. Be  careful  to  disinfect  the  umbilicus  which  should  be 
drawn  out  with  a  pair  of  Kocher's  forceps. 

When  the  skin  disinfection  is  finished  circumscribe  the 
operative  area  with  sterilized  cloth  compresses,  slightly  moist, 
and  thus  limit  our  operative  field.  The  inclined  plane  is  now 
put  at  45  degrees,  the  minimum  to  get  a  satisfactory  result.2 
The  operation  then  commences. 

The  surgeon  is  on  the  patient's  right,  and  behind  him  is  a 
table  on  which  are  the  flat  trays  containing  instruments,  a  box 
of  gauze  compresses,  two  boxes  of  cloth  compresses  (small  and 
large),  and  facing  him  is  the  principal  assistant  with  his  table 
on  which  are  gauze  compresses,  sutures  and  ligatures.  To 
the  surgeon's  right  is  the  second  assistant,  who  will  hold  during 
the  operation  a  valvular  or  ordinary  retractor.  He  may  not 
be  required  if  automatic  retractors  are  used. 

During  the  whole  course  of  the  operation,  the  surgeon  and 
his  assistants  should  avoid  craning  their  hands  over  the  wound 
and  they  should  not  speak  or  breathe  into  the  abdomen,  as  their 
breath  is  infective. 

Abdominal  Incision. — The  ost  generally  employed  incision 
is  the  median  vertical  subumbilical.  It  should  be  long  enough 
to  permit  doing  the  intraabdominal  manipulations  with  ease  and 
yet  not  too  long  so  that  loops  of  intestine  keep  appearing  in  the 
wound.  It  varies  from  4  to  12  cm.  and  more;  an  incision  to 
permit  of  the  extraction  of  large  fibroids  may  attain  great 
dimensions. 

Generally  one  commences  with  a  small  incision  a  little  below 
the  mid  point  of  a  line  between  the  umbilicus  and  pubis.3  Cut 
through  the  skin,  the  subcutaneous  cellular  tissue  and  the 
aponeurosis  in  a  line  with  the  white  line.  In  fact,  the  incision 

1  In  order  to  get  the  best  results  with  the  brush  we  use  a  tampon  of  wood  shavings ; 
as  this  tampon  is  of  no  value,  it.  is  used  once  and  thrown  away.     We  use  liquid  soap  and 
a  little  water  (white  soap  1,  black  soap  1,  oil  1,  water  5,  naphtol,  0.025,  essence  of  citron, 
q.  6.,  in  order  to  perfume  it).     Be  careful  not  to  rub  the  skin  too  hard  as  it  may  be 
broken. 

2  In  exceptional  cases  this  elevated   pelvis  position  is  badly  supported.     In  certain 
short  subjects  the  diaphragm  cannot  support  the  weight  of  the  viscera  which  compresses 
it  and  the  respiration  becomes  rapid  and  stertorous  and  the  pulse  irregular,  the  face 
cyanosed  and  pupils  dilated.     It  is  necessary  to  assume  the  horizontal   position. 

3  In  extremely  fat  women,  Kelly  advises  an  exploratory  incision  at  the  level  of  the 
umbilicus,  a  point  where  the  abdominal  wall  is  thinned  by  reason  of  the  absence  of 
fatty  tissue  and  of  muscular  tissue  between  skin  and   peritoneum. 


302 


ABDOMINAL   CELIOTOMY 


is  rarely  median  and  generally  opens  the  sheath  of  one  of  the 
right  muscles.  It  is  easy  to  recognize  the  internal  border  of 
the  muscle  thus  discovered  and  it  is  liberated  by  a  cut  of  the 
bistoury  along  the  whole  length  of  the  internal  border.  We 
must  go  prudently  in  order  not  to  injure  the  intestines  in  im- 
mediate contact  with  the  deep  surface  of  the  peritoneum.  In 
order  to  avoid  injuring  them,  pinch  up  a  fold  of  the  deep  layers 
of  the  wall  and  then  seize  the  other  side  of  the  fold  with  a  pair  of 


•     FIG.  264. — Incision  of  the  abdominal  wall. 

artery  forceps  and  cut  between  them  with  the  knife  (Fig.  265). 
Often  the  peritoneum  is  immediately  opened;  sometimes  the 
same  manipulation  must  be  repeated  several  times  in  order  to 
cut  through  the  fibers,  fatty  tissue  and  the  peritoneum  before 
opening  the  abdominal  cavity;  as  soon  as  this  is  opened,  enlarge 
it  at  each  end  with  blunt  scissors. 

Insinuate  two  fingers  into  the  incision  thus  made  and  lift  up 
the  whole  thickness   of  the   wall   and  then  enlarge  the  pubic 


OPERATION 


303 


extremity  of  the  wound,  being  careful  not  to  injure  the  bladder, 
and  then  the  umbilical  end. 

When  the  dimensions  of  a  tumor  force  us  to  go  beyond  the 
umbilicus  we  prolong  the  incision  to  the  left  in  such  a  manner 
as  to  avoid  the  suspensory  ligament  and  thus  give  it  sufficient 
dimensions/ 


FIG.  265. — Incision  of  the  peritoneum  between  two  forceps. 

This  incision  usually  cuts  no  vessels  of  importance  and  it  is 
useless  to  place  forceps  on  all  the  bleeding  points.  The  appli- 
cation of  two  sterilized  cloth  compresses  on  the  lips  of  the 
wound  suffice  to  arrest  in  a  moment  all  oozing.  One  or  two 
arterioles  at  the  pubic  angle  of  the  incision  require  to  be  clamped. 

Limitation  of  the  Operative  Field. — The  peritoneum  being 


304  ABDOMINAL   CELIOTOMY 

open,  its  edges  are  seized  with  four  forceps,  and  two  wire  retractors 
are  inserted,  and  the  contents  of  the  abdomen  are  examined. 
This  done,  the  intestines  are  pressed  back  toward  the  dia- 
phragm and  kept  there.  In  order  to  prevent  a  loop  coming 
out  during  the  operation,  we  commence  by  inserting  into  the 
umbilical  angle  of  the  wound  between  the  deep  face  of  the 
wall  and  the  mass  of  intestines,  one  extremity  of  a  compress 
which  we  place  on  the  abdominal  wall  toward  the  xiphi 
sternum.  This  compress  assures  for  us  the  impossibility  of  an 
intestinal  loop,  appearing  in  the  upper  angle  of  the  wound,  and 
we  then  proceed  to  place  other  compresses  to  limit  the  operative 
field.  The  mass  of  intestines  should  be  maintained  by  warm 
compresses,  slightly  moist,  outside  the  operative  field  and  thus 
avoiding  cold  and  traumatism. 


FIG.  266. — Steel  wire  retractors  (Hartmann). 

A  first  compress  is  placed  in  the  superior  angle  of  the  wound, 
which  literally  covers  and  holds  back  the  mass  of  intestines  and 
it  extends  from  the  incision  almost  to  the  promontory.  The  two 
lateral  retractors  are  then  successively  lifted  out  and  two  lateral 
compresses  are  insinuated  under  the  abdominal  walls  in  order 
to  tampon  the  iliac  fossas.  It  is  often  useful  to  double  and 
triple  these  means  of  protection  of  the  intestine  when  the  exami- 
nation of  the  lesions  would  lead  one  to  think  of  the  possible 
rupture  of  a  focus  of  suppurations  in  the  course  of  the  operative 
manipulations.  In  no  case  should  a  compress  be  entirely  intro- 
duced into  the  abdominal  cavity;  one  extremity  should  alwrays 
remain  externally.  We  thus  avoid  the  risk  of  forgetting  one  of 
them  in  the  abdomen,  and  there  is  no  trouble  of  having  to  count 
them  previous  to  the  operation  and  after.  The  pelvic  cavity  thus 


OPERATION  305 

exposed,  we  proceed  to  the  operation  we  have  in  view.  This  is 
more  or  less  easy  according  to  the  purpose  in  view  and  the  state 
of  the  lesions.  In  all  cases,  the  presence  of  adhesions  may 
complicate  the  manipulations. 

Treatment  of  Adhesions. — -We  may  distinguish  two  great 
groups :  inflammatory  and  natural  adhesions. 

Inflammatory  Adhesions. — Adhesions  to  the  wall  are  usually 
easy  to  liberate.  In  some  cases,  however,  they  complicate  the 
opening  of  the  abdominal  cavity  and  one  is  often  puzzled  to  know 
whether  one  is  within  or  out  of  the  peritoneum.  The  simplest 
thing  to  do  in  such  a  case  is  to  prolong  the  incision  toward  the 
umbilicus  in  order  to  penetrate  into  a  cavity  free  of  adhesions  and 
thus  enable  one  to  obtain  an  orientation  of  one's  surroundings. 

The  most  frequent  adhesions  found  are  those  of  the  epiploon. 
When  recent,  separate  them.  It  is  well  to  clamp  pieces  of  sepa- 
rated epiploon  because  they  may  be  the  seat  of  oozing,  more  or 
less  abundant,  and  for  which  it  is  most  often  necessary  to  do  a  re- 
section. When  we  are  dealing  with  old  adhesions,  they  are  too 
firm  to  permit  separation.  It  is  better  in  such  cases  not  to 
waste  time  with  useless  manipulations,  but  to  cut  through  the 
epiploon  above  the  adherent  parts.  When  it  is  necessary  to  do 
extensive  resections,  the  crushing  forceps  render  great  services  in 
reducing  to  a  minimum  the  volume  of  the  epiploic  pedicles. 

Periuterine  adhesions  are  very  troublesome  when  they  mask 
the  body  of  the  uterus.  It  is  difficult  to  ascertain  one's  position. 
In  such  cases  look  for  the  body  of  the  uterus  methodically  as 
follows : 

Commence  by  the  liberation  of  adhesions  immediately 
behind  the  pubis,  at  the  level  of  the  bladder,  and  work  from  in 
front  backward,  being  careful  to  work  always  in  the  median 
line.  We  come  upon  vesico-uterine  cul-de-sac  and  then  on  the 
anterior  surface  of  the  uterus.  Continuing  the  separation  in  this 
manner,  we  at  length  come  into  contact  with  the  body  of  the 
uterus. 

We  liberate  successively  its  fundus  and  posterior  face.  After 
this  we  are  in  the  position  of  a  full  uterus  with  only  the  adnexa 
adherent. 

The  liberation  of  the  adnexa  adhesions  is  generally  easy 
enough  when  they  are  adherent  only  to  the  parietal  peritoneum 

20 


306  ABDOMINAL  CELIOTOMY 

or  to  the  posterior  surface  of  the  broad  ligaments.  It  is  always 
carried  out  in  the  median  line,  working  toward  the  sides  and  pro- 
ceeding from  below  upward.  Use  the  extremities  of  the  fingers 
from  the  commencement  of  operation  to  hook  up  the  adnexa 
from  the  floor  of  the  pouch  of  Douglas.  This  liberation  is  only 
difficult  when  there  are  adhesions  with  the  intestine. 

Intestinal  adhesions  ought  to  be  detached  with  more  care 
because  at  all  costs  we  must  not  open  the  digestive  tract,  the 
wall  of  which,  often  altered  by  inflammation,  becomes  infiltrated, 
friable  and  like  a  paste  board;  also,  if  a  cleavage  is  not  found 
enabling  separation  to  go  on,  it  is  best  to  use  the  knife  and  incise 
the  adherent  adnexa  than  seek  to  separate  afresh.  In  no  case 
should  one  act  with  force,  and  sometimes  it  may  be  deemed 
necessary  or  better  to  leave  a  piece  of  tube  or  pocket  adherent 
to  the  intestine.  However  much  care  is  taken,  the  intestinal 
wall  may  be  wounded  at  the  level  of  these  adherent  points.  If 
the  lesions  occur  only  in  the  musculo-serous  tissues,  some 
Lembert  sutures  suffice.  If  the  mucous  membrane  is  opened, 
a  double  suture,  one  total  and  the  other  sero-serous,  is  absolutely 
necessary. 

Very  exceptionally  in  cases  of  extensive  and  firm  adhesions, 
one  may  be  led  to  do  a  resection  of  the  intestine. 

Vesical  adhesions  much  rarer  are  treated  like  adhesions  of 
the  intestine. 

Natural  Adhesions. — Under  this  misnomer  is  meant  the 
inclusion  of  tumors  under  a  peritoneal  fold.  This  inclusion  is 
seen  particularly  in  fibromas  which  appear  on  the  antero-lateral 
portion  of  the  inferior  segment  of  the  uterus  and,  developing  below 
the  serous  layers  of  the  broad  ligament  which  they  separate,  event- 
ually they  come  to  lie  under  the  peritoneum  in  contact  with  the 
iliac  colon  to  the  left  and  the  cecum  to  the  right.  The  anatom- 
ical disposition  of  the  parts  dictates  the  line  of  conduct  in  such 
cases.  Make  a  circular  incision  of  the  peritoneum  near  the  base 
of  the  tumor  and  attach  to  the  inferior  lip  of  the  incision  a  small 
hemostatic  forceps,  then  separate  off  the  serous  layer  and  be 
careful  to  remain  in  direct  contact  with  the  tumor.  We  thus  avoid 
wound  of  the  intestine  and  above  all  of  the  ureter  which  is  more 
particularly  exposed  in  these  cases  of  tumors  included  in  the 
broad  ligament. 


OPERATION 


307 


Hemostasis. — When  the  tumor  is  freed,  practise  the  hemo- 
stasis.  Remember  that  it  is  illogical  and  dangerous  to  leave 
large  pedicles.  It  is  necessary  to  tie  off  the  different  vascular 
pedicles.  To  do  so  use  a  silk  or  better  still  a  catgut  ligature. 


FIG.  267. — Partitioning  of  the  pelvis  by  suture  of  the  pelvic  colon  to  the  peritoneum  of 
the  anterior  wall  above  a  vaginal  drain. 

In  short,  the  ligature  should  be  of  fine  caliber  as  small  threads 
have  the  double  advantage  of  tying  tightly  and  of  being  better 
tolerated  than  the  enormous  threads  of  silk  which  some  surgeons 
still  wrongly  use.  As  the  pedicles  have  a  constant  position, 


308  ABDOMINAL    CELIOTOMY 

corresponding  to  known  anatomiccal  data,  it  is  easy  to  know  at 
what  points  one  should  place  the  ligatures.  With  the  exception 
of  the  uterine,  utero-ovarian  and  some  funicular  arteries  one  has 
only  to  place  a  few  ligatures  on  bleeding  points  corresponding  to 
secondary  vessels;  the  only  important  point  is  never  to  place 
forceps' on  blindly  and  always  to  see  what  one  does. 

Peritonization. — Excision  accomplished  and  hemostasis  se- 
cured, it  is  necessary  to  peritonize  the  rawer  surfaces  of  the 
true  pelvis  by  making  an  exact  suture  of  the  peritoneum  includ- 
ing in  a  continuous  suture  the  ligatures  and  rawed  surface.  This 
is  done  by  a  curved  needle  in  a  needle  holder.  When  the  surfaces 
to  be  covered  are  very  extensive  or  where  the  peritoneum  is 
inflamed,  thickened,  friable,  and  is  easily  torn  with  the  tight- 
ening of  the  suture,  to  use  the  expression  of  Chaput,  we  have  a 
veritable  transverse  partitioning  of  the  pelvis.  Suture  the 
recto-vesical  peritoneum  to  that  which  covers  the  pelvic  colon 
and  the  superior  part  of  the  rectum,  isolating  large  peritoneal 
cavity,  the  operative  field  which  is  left  in  communication  with 
the  vagina  (Fig.  267).  This  partitioning  off,  as  in  all  peritoni- 
zation  of  the  pelvis,  is  carried  out  very  rapidly  with  a  curved 
needle  in  a  needle  holder  and  threaded  with  fine  catgut;  this 
method  appears  very  superior  to  us,  as  regards  facility  and 
rapidity,  to  the  suture  with  Reverdin's  needle  wrhich  my  Parisian 
colleagues  still  employ  greatly. 

Examination  of  the  Appendix. — -Before  closing  the  abdominal 
wall  it  is  always  of  advantage  to  draw  in  the  cecum,  to  examine 
the  appendix,  and  if  it  presents  any  lesions  to  remove  it  at  once. 
The  systematic  removal  of  the  appendix  has  been  advised  by 
many  operators  in  all  cases  in  which  the  abdomen  has  been 
opened  for  a  lesion  of  the  gynecological  order.1 

Closing  of  the  Abdominal  Wall. — A  final  abdominal  toilet 
having  been  done,  the  closing  of  the  abdominal  wall  alone  remains. 
It  is  well  to  lower  the  inclined  plane  and  see  if  there  is  bleeding 
in  the  pelvic  cavity,  when  the  patient  is  horizontal.  This  may 
occur  whereas  it  did  not  exist  in  the  Trendelenburg  position. 

1  Kelly  uses  the  abdominal  opening  to  explore  other  regions.  He  has  been  able  not 
only  to  discover  appendicular  lesions  but  also  a  movable  kidney,  biliary  calculi,  ureteral 
lesions  and  even  a  pyloric  tumor.  (Kelly,  Exploration  as  an  adjunct  to  every  celiotomy. 
Medical  News,  1899,  p.  784.)  We  believe  that  this  systematic  abdominal  exploration 
is  inferior  to  a  precise  examination  associated  with  a  methodical  interrogation  of  the 
patient  before  the  operation. 


OPERATION 


309 


Now  remove  the  compresses  that  protect  the  intestines.  T\ie 
intestines  are  allowed  to  come  back  into  the  pelvis  and  then  the 
epiploon  is  sought  and  it  is  spread  out  in  front  of  the  intestines; 
in  order  to  isolate  the  peri-intestinal  serous  membrane  from  the 
operative  field  and  prevent  any  secondary  intestinal  occlusion 
due  to  a  kink  of  the  transverse  colon  which  has  fallen,  at  the 
moment  of  the  pelvis  being  raised,  into  the  diaphragmatic 
concavity,  and  remained  in  that  abnormal  situation  till  the 


FIG.  268. — Suture  en  masse. 
The  parts  are  badly  apposed 
and  the  aponeurosis  is  folded  up 
between  the  muscles. 


FIG.  269. — Suture  en  masse.  The 
parts  have  been  well  apposed,  peri- 
toneum to  peritoneum,  muscle  to  mus- 
cle, and  aponeurosis  to  aponeurosis. 


patient  is  in  the  horizontal  position.  Each  surgeon  has  his 
own  way  of  closing  the  abdominal  wall ;  to  be  honest,  the  manner 
is  of  little  importance,  provided  that  the  suture  remains  aseptic 
and  retains  similar  parts  in  connection. 

The  suture  may  be  employed  either  in  one  plane  or  several 
planes. 

The  one  plane  suture  may  be  done  with  the  aid  of  large  silk- 


FIG.  270. — Needle  with  handle  (Doyen). 

worm-gut  sutures,  of  large  silks  or  even  better  metallic  sutures 
(silver  wire,  or  sutures  of  aluminium  bronze). 

The  suturing  excites  nothing  special.  It  is  important,  how- 
ever, to  see  that  the  needle  does  not  escape  the  muscle  and 
aponeurosis,  and  that  it  is  inserted  as  near  as  possible. 

Better  than  all  descriptions,  Figs.  268  and  269  show  the  points 
\vhere  the  needle  should  traverse  the  different  planes.  This 
method  of  suturing  has  for  its  object  the  prevention  of  the  perit- 


310 


ABDOMINAL   CELIOTOMY 


oneum  being  drawn  between  the  two  lips  of  the  wound  and  that 
the  skin  may  be  cut  through  by  silver  wires  which  would  embrace 
the  extended  area.  The  sutures  are  placed  2  cm.  apart,  and 
passed  with  the  aid  of  a  solid  needle  provided  with  a  handle. 
Place  all  the  sutures  first  and  tie  them  later  and  take  care  that 


FIG.  271. — Suture  in  three  layers.  FIG.  272. — Hagedorn's  needles. 

at  the  moment  of  tension  there  is  neither  intestine  nor  epiploon 
in  the  suture  loop. 

The   deep   sutures   having   been   inserted,    some  superficial 


FIG.  273. — Needle  mounted  on  Doyen's  needle  holder. 


silkworms  or  Michel's  agrafes  are  placed  between  them  in  order 
to  get  an  accurate  apposition  of  the  skin. 

If  one  uses  the  many  suture  plan,  unite  first  the  peritoneum, 
then  the  musculo-aponeurotic  layer  and  lastly  the  integuments 
(Fig.  271).  Use  either  silk,  cotton  or  catgut. 


OPERATION 


311 


We  use  catgut  sterilized  in  alcohol  under  pressure  for  the 
suture  of  the  peritoneum  and  lightly  chromicized  catgut  for  the 
musculo-aponeurotic  layer1  and  silkworm  gut  for  the  skin.  We 
do  a  continuous  suture  of  the  peritoneum  with  one  of  Hage- 
dorn's  needles  held  in  the  hand  interrupting  the  suture  after 


M. 


FIG.  274. — The  continuous  peritoneal 
suture  is  finished.  Suture  of  the  musculo- 
aponeurotic  wall. 


FIG.  275. — Cutaneous  suture  (deep 
and  superficial  sutures). 


every  four  or  five  insertions.  For  the  suture  of  the  more  difficult 
musculo-aponeurotic  layers  we  use  a  so-called  fistula  needle  held 
with  a  needle  holder.  We  do  a  continuous  suture  taking  up  all 
the  thickness  of  the  musculo-aponeurotic  layer,  being  careful  to 
interrupt  the  suture  after  every  second  insertion  (Fig.  274). 

1  The  catgut  sterilized  in  alcohol  under  pressure  is  absorbed  very  quickly  in  5  or  6 
days,  while  chromicized  catgut  takes  about  25  to  26  days  to  resorb.  It  is  particularly 
useful  for  suture  of  the  resistant  part  of  the  wall,  the  muscles  and  aponeuroses. 


312 


ABDOMINAL   CELIOTOMY 


The  suture  of  the  skin  is  an  interrupted  one  and  is  made  with 
Reverdin's  needle  (Fig.  275). 


FIG.  276. — Intradermic  suture. 


FIG.  277. — The  peritoneum  is 
sutured  on  the  left  side,  the  fatty 
tissue  which  covered  the  anterior 
surface  of  the  aponeurosis  has  been 
removed.  The  aponeurosis  will 
be  doubled  by  the  superposition  of 
that  of  the  right  side. 


FIG.  278. — The  recti  muscles 
are  sutured.  The  aponeurosis 
is  doubled  and  maintained  in 
position  by  a  continuous  suture 
(Noble). 


Different  Methods   of  Suture. — Numerous   have    been   the  methods 
described.     We  cannot  give  all,  but  will  give  the  principal. 

A  suture  often  employed  for  the  skin  is  the  intradermic  suture  described 


OPERATION 


313 


a  long  time  ago  by  Chassaignac,  taken  up  by  the  American  surgeons  and 
recommended  by  Pozzi.  It  is  done  with  a  very  fine  suture  and  a  Hagedorn's 
needle,  short  and  curved.  The  superior  angle  .of  the  wound  is  fixed.  Each 
edge  of  the  wound  is  seized  with  dissecting  forceps  slightly  put  on  tension, 
and  retro  verted.  One  forceps  is  held  by  the  surgeon  and  the  other  by  his 
assistant.  Tlie  needle  penetrates  at  first  about  a  centimeter  above  the  wound 


FIG.  279. — Lace  suture  left 
loose  (Roggers). 


FIG.  280. — Lace  suturje 
drawn  tight  and  tied 
(Roggers). 


or  at  the  side,  near  the  angle,  and  then  completely  traverses  the  skin  and 
comes  out  on  the  wound  bringing  with  it  the  suture  which  is  drawn  up 
until  stopped  by  the  knot.  The  needle  is  then  engaged  in  the  skin  of  the 
opposite  lip  which  it  traverses,  comes  out,  etc.  (Fig.  276).  At  the  extremity 
of  the  wound  it  perforates  completely  the  skin  and  is  finally  knotted. 


FIG.  281.— Suture  in  figure-of-8. 

The  suture  by  doubling  of  the  aponeurosis  which  we  used  for  a  long  time  in 
curing  eventrations  with  extensive  separation  of  the  recti  muscles,  is 
correctly  practised  by  Noble.  After  uniting  the  peritoneum  by  an  absorbable 
catgut  in  continuous  suture,  he  takes  some  chromicized  catgut  and  unites  the 
aponeurosis  of  the  transversalis  and  rectus  with  a  continuous  suture.  Then, 
having  arrived  at  the  extremity  of  the  wound,  he  passes  the  same  suture 


314 


ABDOMINAL   CELIOTOMY 


through  the  anterior  layer  of  the  aponeurosis  which  he  sutures  to  that  of  the 
opposite  side,  thus  superimposing  one  of  the  sides  on  that  of  the  other. 

The  lace  suture  as  carried  out  by  Roggers,  if  it  comprises  the  three  planes 
of  the  wall,  brings  the  parts  into  accurate  apposition,  and  may  be  in  some 
cases  of  repeated  celiotomy  untied  and  unlaced  like  a  corset.  One  has  only 
to  cut  the  suture  below  the  knot  at  the  pubic  extremity  of  the  wound. 

The  figure-of-8  suture  gives  a  good  apposition.  It  is  usually  made  to 
comprise  the  three  planes  (Fig.  281);  personally,  when  we  have  recourse  to  it, 
we  do  a  continuous  catgut  in  the  perineum  and  only  place  the  figure-of-8  in 
the  musculo-aponeurotic  sheath  and  skin,  using  silkworm  gut. 


FIG.  282. — Suture  of  the  abdominal  wall  with- 
out buried  sutures  (insertion  of  sutures) . 


FIG.  283.— Suture  of  the  ab- 
dominal wall  without  buried 
sutures  (operation  terminated). 


Jonesco  inserts  a  single  row  of  metal  sutures  of  a  U-shape  whose  extremities 
come  out  through  the  skin,  the  loops  comprise  the  two  deep  aponeuroses,  the 
recti  muscles,  the  two  anterior  aponeurotic  sheaths  without  touching  the 
skin  of  the  opposite  side.  These  are  tied  on  a  roll  of  gauze.  Some  comple- 
mentary silkworm-gut  sutures  complete  the  cutaneous  apposition  (Figs.  282 
and  283).  Gauthier  employs  the  sewing  machine  suture. 

Amann's  suture  is  a  little  special  and  is  easily  understood  by  a  glance  at 
Figs.  285  and  286.  It  is  to  be  noted  that  Amann,  instead  of  making  an 
exactly  median  incision,  splits  the  anterior  aponeurosis  of  the  right  rectus 
laterally;  presses  back  the  internal  lip  of  the  aponeurotic  incision  and  then 


OPERATION 


315 


separates  the  muscles  and  opens  the  peritoneum  in  the  median  line.  In  this 
way  the  aponeurotic  incision  is  opposite  intact  muscles  which  diminishes 
the  risk  of  eventration. 

Drainage. — During  the  last  fifteen  years  there  has  been  an 
effort  to  restrict  the  domain  of  drainage;  we  believe  this  to  be 
wrong.  Certainly  the  peritoneum  has  great  powers  of  absorp- 
tion and  very  real  properties  of  defense.  The  improvements  in 


FIG.  284. — Sewing  machine  suture. 

teclmic,  notably  that  of  peritonization  of  the  pedicles,  have  placed 
the  peritoneum  in  a  favored  position  to  engage  the  struggle  with 
an  infective  process.  We  wish  to  show  that  drainage  not  only 
presents  no  inconvenience  but  notably  ameliorates  the  operative 
results  in  a  certain  number  of  cases  as  we  have  had  occasion  to 
show  in  an  analysis  of  ours  on  1000  cases  of  consecutive 
celiotomy. l 


FIG.  285. — Amann's  suture  untied. 


FIG.  286. — Amann's  suture  tied. 


In  every  operation  conducted  aseptically  and  concluded  with 
perfect  hemostasis,  drainage  is  of  no  use.     But  it  is  indispen- 

1  Hartmann  and  Metzger,  Abdominal  Drainage  in  Gynecology  in  997  Consecutive 
Celiotomies.     Ann.  de  Gyn.,  Paris,  1910,  p.  329. 


316 


ABDOMINAL   CELIOTOMY 


sable  when  for  some  reason  or  other  there  is  a  fear  that  there 
may  have  been  infection  of  the  pelvic  cavity  or  if  one  fears 
the  production  of  either  a  serous  or  hemorrhagic  oozing. 

That  is  to  say  that  drainage  is  indicated  in  the  course  of  an 
operation  where  a  suppurating  pocket  has  been  ruptured  or 
where  a  diseased  intestine  is  found  or  when  one  is  forced  to 
leave  in  the  abdomen  a  fragment  of  the  inflamed  pocket. 

It  is  even  necessary  when  hemostasis  is  not  perfect  and  the 
peritonization  is  not  complete  and  where  surfaces  remain  capable 
of  oozing. 

From  wrhere  should  one  drain  ?  Some  drain  by  the  vagina 
and  others  by  the  lower  part  of  the  abdominal  wound.  These 


FIG.  287. — Abdominal  drainage  after  total  castration;  the  omentum  falls  like  an 
apron  in  front  of  the  mass  of  intestines  and  thus  isolates  the  drainage  area. 

two  methods  have  their  advantages  and  their  defenders  and  both 
appear  to  give  good  results.  The  important  point  is  to  drain  a 
limited  cavity.  Also  at  the  moment  of  insertion  of  the  drain 
bring  all  the  altered  intestinal  surface  into  contact  with  it.  Iso- 
late the  pelvic  colon  and  the  great  omentum,  folded  down  like  an 
apron,  and  the  large  peri-intestinal  peritoneum  from  the  drainage 
area  in  the  pelvis. 

The  rapidity  with  which  adhesions  form  suffices  to  isolate 
our  infective  area  almost  immediately  and  there  is  no  fear  of 
infective  complications  developing  elsewhere  in  the  abdomen 
(Fig.  287). 

Each  of  these  methods  has  its  indications.  Where  the 
uterus  has  not  been  completely  removed,  we  drain  by  the  ab- 


OPERATION 


317 


domen.  The  reproach  levelled  at  this  method,  to  the  effect 
that  the  exudates  on  the  pelvic  floor  are  not  drained  off,  is  not 
founded  because  there  is  always  an  intraabdominal  pressure 
opposed  to  the  force  of  gravity.  A  large  rubber  drain  in  the 
inferior  angle  of  the  wound  and  fixed  by  a  silkworm  gut  assures 
the  perfect  evacuation  of  fluid  without  aspiration.  We  prefer 
this  to  the  glass  drains  which  may  break  or  exercise  dangerous 
pressure  on  neighboring  organs,  and  to  gauze  drains,  because 
the  removal  of  these  last  is  so  painful;  and  if  the  drain  is  not  in 
contact  with  the  part  that  oozes,  it  may  act  like  a  cork  and 
imprison  the  exudates. 

During  the  first  24  or  48  hours  the  oozing,  sometimes  abun- 
dant, obliges  us  to  renew  fairly  frequently  the  dressing.     The 


FIG.  288. — Vaginal  drainage.  Alongside  the  drain  in  the  vagina  is  a  gauze  wick. 
The  drainage  area  is  isolated  from  the  large  peri-intestinal  serous  membrane  by  a  suture 
uniting  the  pelvic  colon  to  the  retro-vesical  peritoneum. 


drain  may  be  drawrn  out  in  aseptic  operations  as  early  as  the 
second  day.  To  avoid  the  entry  of  omentum  into  the  lateral 
orifices  of  the  tube,  it  is  well  to  rotate  it  before  drawing  it  out. 
If  the  uterus  has  been  entirely  removed  and  an  exact  peritoni- 
zation  has  not  been  carried  out  and  one  has  had  recourse  to  the 
partitioning  of  the  pelvis  we  drain  by  the  vagina.  We  fix  the 
extremity  of  the  drain  to  the  edges  of  the  incision  with  a  non- 
chromicized  catgut  (Fig.  288). 

Drainage   by  Gauze. — This  has   been   particularly  recommended   by 
Mikulicz,  who  operated  in  the  following  manner:  He  took  a  piece  of  steril- 


318  ABDOMINAL  CELIOTOMY 

ized  gauze,  square  in  shape,  as  large  as  a  pocket  handkerchief,  in  the  center 
of  which  is  fixed  a  long  and  strong  silk.  Fold  the  gauze  like  a  cone,  and  seize 
the  end  with  a  pair  of  forceps  and  push  it  to  the  limit  of  the  operative  area. 
Introduce  into  its  interior  a  series  of  wicks  in  order  to  fill  it  and  to  tampon  the 
pelvis.  Take  out  the  wicks  in  48  hours  and  the  sac  itself  on  the  fourth  or 
fifth  day. 

Some  surgeons  combine  the  gauze  wicks  and  drainage  tubes,  using  one 
of  Mickulicz's  sacs  in  which  they  place  a  drain  and  at  the  same  time  some 
gauze  wicks;. others  simply  introduce  a  drain  and  place  around  it  some  gauze 
wicks,  which  tampon  the  raw  surfaces.  All  the  procedures  were  good  when 
a  hemostatic  packing  was  as  necessary  as  a  drain,  but  now  hemostasis  must 
be  perfect  before  the  wound  is  closed. 

In  America  a  cigarette  drain  is  used  consisting  of  a  rubber  tube  contain- 
ing a  gauze  wick. 

Lavage  of  the  Peritoneum. — Some  gynecologists  still  recom- 
mend lavage  of  the  peritoneum  in  cases  where  the  operation  has 
been  prolonged,  in  those  where  it  was  necessary  to  drain  off 
debris,  cystic  fluid,  etc.  The  introduction  of  a  certain  quantity 
of  normal  saline,  at  a  temperature  a  little  higher  than  that  of 
the  body,  would  have  the  advantage,  according  to  them,  of 
washing  out  foreign  bodies,  of  acting  as  a  general  stimulant  in 
shock,  jof  diluting  toxic  substances  and  favoring  leucocytosis. 
Personally,  we  have  never  had  recourse  to  it,  seeking,  on  the 
contrary,  to  perform  the  operation  in  a  limited  cavity  and 
greatly  preferring,  in  cases  where  it  is  indicated,  to  combine 
drainage  with  large  subcutaneous  injections  of  serum. 

Dressing. — The  dressing  is  in  no  way  out  of  the  ordinary. 
Apply  compresses  of  sterilized  gauze  to  the  wound,  placing,  if 
there  is  a  drain,  a  certain  number  of  folded  compresses  about  it. 
Above  the  gauze  place  sterilized  hydrophile  wool,  then  ordinary 
wool  and  bandage  with  flannel  so  applied  as  to  exercise  an  elastic 
compression  on  the  abdomen,  to  immobilize  the  wound  and  to 
protect  it  from  external  shocks  and  to  maintain  a  constant 
temperature  about  the  wound. 

If  the  operation  has  been  a  little  long  and  if  the  patient  has 
lost  a  considerable  quantity  of  blood,  it  is  distinctly  indicated 
before  her  removal  to  her  bed  to  inject  with  a  can  and  a  fairly 
long  rubber  tube,  3  to  500  c.c.  of  saline  solution  in  proportion  of 
up  to  1000. 


OPERATION 


319 


FiG.  289. — Incision  in  transverse  celiotomy. 


FIG.  290. — The  cutaneo-aponeurotic  flap  is  raised. 


320 


ABDOMINAL   CELIOTOMY 


B.  Transverse  Celiotomy. 

If  there  is  not  a  large  tumor,  no  suppurative  lesions,  no 
special  operative  difficulties,  we  may  substitute  for  the  median 
vertical  and  median  incision,  the  transverse  incision.  To  the 
suprapubic  transverse  incision,  generally  adopted  by  the  German 
gynecologists,  we  prefer  a  curved  incision  with  its  summit  just 
approaching  the  pelvis  and  the  extremities  mounting  laterally  to 
the  limit  of  the  region  of  the  pubic  hair. 

After  incising  the  anterior  abdominal  aponeurosis,  we  raise 


FIG.  291. — The  peritoneum  is  incised  vertically  after  retraction  of  the  recti. 

the  flap  formed  of  skin,  subcutaneous  fatty  tissue  and  anterior 
abdominal  aponeurosis,  placing  forceps  on  the  numerous  bleed- 
ing points.  From  this  point  the  operation  proceeds  as  usual. 
The  recti  muscles  are  separated  in  the  median  line  and  the  fascia 
transversalis  and  peritoneum  are  opened  vertically.1 

When  the  intraabdominal  operation  is  finished  close  the 
abdomen  by  suturing  the  peritoneum  vertically,  then  the  recti, 
then  the  aponeurosis  transversely  and  finally  the  skin.  The 

1  Kiistner  suggested,  with  a  purpose  purely  cosmetic,  the  transverse  cutaneous  inci- 
sion. He  raised  the  skin  and  then  the  subcutaneous  fatty  tissue,  and  incised  the 
musculo-aponeurotic  wall  vertically.  Pfannenstiel  modified  this  operation  by  cutting 
the  aponeurosis  transversely  and  separating  the  muscles  vertically  so  as  to  obtain  a 
more  solid  wall.  (J.  Pfannenstiel,  Ueber  die  Vprtheile  des  suprasymphysaren  Fascien- 
querschnitts  fur  die  gynakologischen  Kceliotomien.  Samml.  klin.  Vortr.,  1900.) 


AFTER-TREATMENT  321 

advantage  of  this  operation  is  that  the  cicatrix  is  hidden  by  the 
pubic  hair  and  also  that  it  leaves  a  solid  wall  as  the  lines  of 
sutures  are  in  two  planes  reciprocally  perpendicular. 

The  inconvenience  of  the  operation  is  that  it  lasts  longer, 
requires  a  more  perfect  antisepsis,  and  that  it  gives  only  a  limited 
sphere  of  action.  The  last  consideration  is  improved  by  the 
curved  incision  we  advise  in  preference  to  that  employed  by 
the  Germans.  If  one  requires  a  larger  sphere  of  action,  prolong 
the  extremities  upward  and  outward,  so  as  to  have  a  flap  with  a 
broader  base  which  may  be  raised  higher  and  thus  enlarge  the 
space  between  the  two  recti. 

Bardenheuer  employs  often  a  large  incision  convex  below, 
extending  from  one  iliac  spine  to  the  other,  and  cuts  through  the 
large  recti  muscles  above  their  insertion  into  the  symphysis  pubis. 
This  incision,  which  gives  a  fine  working  space,  diminishes  the 
solidarity  of  the  wall. 

4.  After-treatment. 

When  the  dressing  is  finished  the  patient  should  be  immedi- 
ately taken  to  her  bed,  which  has  been  warmed.  Use  hot  water 
bottles.  Do  not  leave  them  in  contact  with  the  skin  as  the 
anesthetized  part  may  be  very  badly  burnt. 

It  is  essential  that  either  the  chloroformist  or  experienced 
nurse  remain  at  her  side  until  she  emerges  from  the  anesthetic. 
Before  even  the  awakening  is  completed,  inject  into  the  intestine 
with  a  long  cannula  a  certain  quantity  of  artificial  serum  or  even 
inject  it  subcutaneously. 

The  patient  is  maintained  for  some  hours  following  the 
operation  with  lowered  head,  and  knees  semiflexed  over  a 
pillow.  This  horizontal  position  is  useful  to  combat  the  effects 
of  acute  anemia,  collapse,  shock  and  also,  in  a  certain  measure, 
chloroform  vomiting.  But  it  must  not  be  too  prolonged.  As 
soon  as  she  comes  out  of  the  anesthetic  sleep  replace  the  pillow 
and  cause  her  to  breathe  deeply  and  in  a  word  produce  a  series  of 
gymnastic  respiratory  exercises.  The  most  complete  calm  should 
reign  about  the  patient,  leaving  her  at  first  in  semiobscurity, 
while  assuring  oneself  of  the  ventilation  of  the  room  in  order  not 
to  have  an  atmosphere  full  of  chloroform  vapor  exhaled  by  the  lungs. 


21 


322  ABDOMINAL  CELIOTOMY 

If  pains  still  persist  give  a  little  morphine  or  heroin  sub- 
cutaneously  (1/4  or  1/2  cm.  repeated  as  required).  In  the 
evening,  if  the  chloroform  vomiting  has  ceased,  commence  to 
give  lightly  alcoholized  drinks  (champagne  or  grog) ;  on  the 
following  day  give  milk  and  on  the  day  following  a  light  soup, 
returning  in  short  to  a  normal  dietary  very  quickly. 

On  the  day  following  the  operation  without  waiting,  as  before 
for  the  patient  to  complain  of  colic  or  meteorism,  insert  a  sound 
into  the  rectum.  The  presence  of  this  sound  leads  to  an  emission 
of  gas  and  is  a  great  relief  to  the  patient.  Even  on  the  following 
day  or  at  latest  the  second  day  give  a  laxative1  or  enema.  If 
some  intestinal  adhesions  with  difficulty  liberated  and  sutured 
make  us  fear  for  the  state  of  the  intestine  the  purgative  should 
be  preferred  to  the  enema. 

To  the  liquids  given  in  the  beginning,  it  is  necessary  to  ad- 
vance progressively  after  the  intestinal  evacuation  to  solid  food. 

The  stitches  are  taken  out  from  the  seventh  to  the  tenth  day; 
on  the  seventh,  if  it  is  a  case  with  stitches  in  several  layers,  and 
on  the  tenth  or  eleventh  if  the  sutures  have  embraced  the  tissues 
en  masse;  often  the  stitches  are  not  all  taken  out  at  once.  We 
commence  with  those  that  are  surrounded  by  an  areola  of  red 
and  slightly  red  and  cut  the  skin. 

If  a  drain  has  been  used,  when  should  it  be  removed?  This 
may  be  done  in  twenty-four  or  forty-eight  hours,  if  the  operation 
results  are  normal.  But  it  is  often  necessary  to  prolong  the 
drainage  several  days.  In  a  general  way,  the  matter  is  decided 
by  the  temperature  chart  and  the  amount  of  fluid  passed  by  the 
drain. 

If  the  convalescence  goes  on  without  incident,  the  patient  is 
now  allowed  to  sit  up  in  bed  and  she  is  given  several  pillows  to 
support  her.  She  is  allowed  to  get  up  on  the  fifteenth  day. 

There  is  no  fixed  rule  to  guide  us ;  it  is  certain  that  a  patient 
having  undergone  a  slight  operation  and  whose  abdominal  wall 
is  accurately  sutured  may  get  up  soon,  but  it  is  of  advantage  to 
keep  in  bed  those  patients  who  were  much  run  down  before  the 

1  The  stimulation  of  the  intestinal  peristalsis  is  useful.  Vogel  and  R.  v.  Hippel  insist 
on  it  and  inject  immediately  after  the  operation  a  milligram  of  physostigmine,  which  is 
repeated  every  3  hours  until  the  bowels  move.  (R.  v.  Hippel,  Centr.-Blatt.  f.  Chir.,  1907, 
p.  1345.)  Lucas  Champonniere  in  France  has  for  years  insisted  on  the  advantage  of 
early  movement  of  the  intestines. 


COMPLICATIONS  OF  CELIOTOMY  323 

operation  and  who  have  lost  very  much  blood  or  been  drained, 
or  have  feeble,  relaxed  and  badly  united  abdominal  walls. 

We  are  not  of  the  opinion,  contrary  to  many  Germans,  that 
early  rising  from  bed  lessens  the  danger  of  thrombi  and  emboli ; 
these  are  septic  complications  and  we  cannot  understand  how 
early  movements  of  the  operated  patients  should  protect  from 
these  complications.  Some  recently  published  works,  however, 
show  that  we  insist  on  a  too  lengthy  immobilization  of 
the  patients  and  that  without  going  so  far  as  to  insist  on  patients 
getting  up  in  48  hours  or  three  days  after  the  operation,  it  is  well 
to  remove  them  from  bed  earlier  than  we  do.  The  respiration  and 
circulation  are  thus  stimulated  and  they  are  placed  in  better 
circumstances  in  order  to  reassume  a  normal  existence. 

It  is  habitual  to  advise  the  patient  to  wear  a  belt;  this  is  prob- 
ably of  no  great  service  for  thin  patients  with  solid  abdominal 
walls.  It  is  indispensable  in  fat  patients  with  flabby  ab- 
dominal walls  and  those  who  have  been  drained. 

5.  Complications  of  Celiotomy. 

We  may  have  a  number  of  complications  after  celiotomy. 

Shock. — Under  the  heading  of  shock  is  comprised  a  complex 
symptomatology  characterized  by  elevated  temperature,  pallor 
of  face  and  cardio-vascular  collapse;  the  extremities  are  cold, 
respiration  short,  frequent  and  irregular;  pulse  small,  fast; 
there  is  cerebral  torpor,  an  indifferent  facial  expression,  while  at 
the  same  time  the  intelligence  is  preserved. 

It  is  necessary  to  get  the  patient  warm  by  all  means  in  our 
power  (hot  bottles,  extra  blankets,  etc.),  to  stimulate  the  heart 
by  injections  of  strychnine,  sparteine,  caffeine,  camphorated  oil, 
and  the  respiration  by  inhalations  of  oxygen.  Lightly  tap  the 
face  and  if  necessary  do  rhythmic  traction  of  the  tongue  and 
combat  the  lack  of  vascular  tension  by  injections  of  normal 
saline. 

Most  frequently  the  patient  gradually  recovers;  sometimes, 
however,  complications  ensue  and  lead  more  or  less  rapidly  to 
fatal  termination. 

Internal  Hemorrhages. — If  the  complications  of  shock  con- 
tinue to  increase  instead  of  diminish,  we  are  forced  to  think  of 


324  ABDOMINAL  CELIOTOMY 

internal  hemorrhage.  This  manifests  itself  in  a  certain  number 
of  hours ;  the  patient  is  awakened ;  she  seems  as  if  she  were  getting 
well  when  she  experiences  abdominal  pain  and  the  pulse  becomes 
small  and  thready;  the  face  and  mucous  membranes  blanche, 
and  there  is  a  tendency  to  syncope,  etc.  The  ultra-rapid  evolu- 
tion of  these  complications  which  come  on  some  few  hours  after 
the  operation  should  not  be  confounded  with  signs  of  peritoneal 
infection  which  appear  later,  and  whose  course  is  less  rapid. 

In  presence  of  an  internal  hemorrhage  don't  wrait  for  thera- 
peutic anodynes  such  as  ice  applied  to  the  abdomen.  Precious 
time  is  thus  lost  and  the  life  of  the  patient  may  depend  on  a  few 
minutes  saved  at  the  beginning.  We  must  immediately  open  the 
abdomen,  find  the  bleeding  point,  and  secure  it.  Intravenous 
injections  of  serum  render  signal  service. 

Septic  Peritonitis. — Septic  peritonitis  commences  toward  the 
middle  of  the  second  day.  Vomiting  or  more  often  hiccough, 
rise  of  temperature,  coldness  of  the  extremities,  acceleration  of 
respiration,  an  abdominal  facies,  a  small  and  cracked  voice  and 
above  all  the  small  and  rapid  pulse  are  the  cardinal  symptoms 
that  announce  the  apparition  of  this  complication.  The  local 
signs  are  more  variable.  In  grave  and  rapid  forms  the  abdomen 
remains  supple,  painless  and  sometimes  not  ballooned.  In 
slower  forms  the  peritoneal  reaction  is  evidenced  by  a  more  or 
less  acute  pain  and  a  ballooning  of  the  abdomen  more  or  less 
marked.  This  complication  is  generally  fatal.  The  attempts 
made  up  to  the  present  to  combat  post- operative  peritonitis 
(secondary  drainage,  continuous  irrigation  of  the  peritoneum, 
etc.)  do  not  appear  to  have  given  much  result  and  the  thera- 
peutic treatment  remains  purely  medical  (massive  injections 
of  normal  saline,  collargol,  electrargol,  caffeine,  etc.). 

In  less  severe  forms  after  infection,  if  there  is  no  drainage, 
remove  some  of  the  sutures  and  place  a  large  drain  in  the  floor 
of  the  pelvis,  reducing  the  intervention  to  a  minimum.  Place 
the  patient  in  the  half-sitting  position  and  give  at  the  same  time 
subcutaneous  and  intravenous  injections  of  saline,  injecting 
slowly,  using  a  long  sound  into  the  rectum,  beginning  eight 
hours  after  the  intervention  to  give  calomel  in  fractional  doses; 
in  short,  doing  the  Murphy's  treatment  for  acute  peritonitis. 
••  Slight  Peritonitis. — In  the  slight  infections  characterized 


COMPLICATIONS  OF  CELIOTOMY  325 

principally  by  tympanites,  elevation  of  pulse  and  temperature, 
vomiting,  complete  arrest  of  fecal  matter  and  gas,  the  indication 
is  to  give  a  purgative  in  fractional  doses  every  twenty  minutes 
a  soup  spoon  of  a  solution  of  60  grams  (e.g.,  1^  ounces)  of  sul- 
phate of  spda  in  200  c.c.  of  Vichy  water,  stopping  as  soon  as 
there  is  emission  of  gas  or  fecal  matters  by  the  anus,  and  continu- 
ing if  not  successful  to  give  the  whole  of  the  mixture  irrespective 
of  vomiting. 

At  the  same  time  inject  three  hourly  under  the  skin  1  c.c. 
(20  minims)  of  10  per  cent,  camphorated  oil  in  order  to  support 
the  heart.  By  these  simple  means  we  often  obtain  a  cessation 
of  these  complications. 

Intestinal  Occlusion. — Intestinal  occlusion  is  much  rarer 
than  the  foregoing.  It  is  characterized  by  vomiting,  a  complete 
arrest  of  fecal  matters  and  gas,  ballooning  with  peristaltic 
undulations  of  the  intestine,  the  preservation  of  a  good  facies, 
good  pulse  and  without  elevation  of  temperature. 

Reopen  the  intestine  and  explore  the  seat  of  the  primary 
intervention;  generally  there  is  an  adherent  intestinal  loop  to  be 
found.  If  nothing  of  this  nature  be  found,  look  for  a  kink  of  the 
colon ;  if  this  does  not  exist,  we  must  make  an  artificial  anus. 

Acute  Dilatation  of  the  Stomach. — Acute  dilatation  of  the 
stomach  is  characterized  by  vomiting,  an  alteration  of  the  features, 
an  accelerated  and  small  pulse  and  an  epigastric  ballooning 
which  gradually  extends.  Treatment  is  directed  to  the  washing 
out  of  the  stomach.  Then  place  the  patient  in  the  ventral 
position.  These  symptoms  seem  to  correspond  to  a  strangula- 
tion of  the  third  part  of  the  duodenum  by  the  mesenteric 
pedicle. 

Parotitis. — Parotitis  results  from  an  infection  from  the  mouth, 
and  extending  into  the  gland  \vhose  secretion  is  diminished  by 
reason  of  the  dehydration  of  the  patient  and  absence  of  mastica- 
tion. This  may  be  prevented  by  a  rigid  antisepsis  of  the  mouth 
and  early  ingestion  of  liquids.  If  the  parotitis  is  developed, 
resolution  may  be  easily  obtained  by  the  expression  of  the  gland, 
combined  with  external  applications  of  hot  moist  compresses 
and  cleansing  of  the  mouth.  When  an  abscess  is  imminent, 
open  the  gland  by  a  small  incision  directed  parallel  to  the  branches 
of  the  facial  nerve. 


326  ABDOMINAL  CELIOTOMY 

Pulmonary  Complications. — These  are  often  seen  associated 
with  one  of  the  preceding  complications,  occlusion  or  infection. 

They  may  nevertheless  come  on  independently  of  these  last 
and  constitute  of  themselves  a  grave  complication.  We  fear  it 
greatly  in  aged  subjects  already  suffering  from  a  chronic  pul- 
monary infection,  or  with  cardiac  or  renal  lesions.  Fat  subjects 
are  specially  liable  to  this  complication.  It  may  be  avoided  by 
strict  attention  to  the  cleansing  of  the  mouth  in  preventing,  during 
anesthesia,  vomited  matters  entering  the  respiratory  passages  and 
in  avoiding  carefully  exposure  to  cold  during  and  after  the  opera- 
tion, in  keeping  the  patients  sitting  up  in  bed  after  the  operation 
and  preserving  the  trunk  vertical  during  the  greater  part  of  the 
day.  We  advise  also  as  soon  as  there  is  the  least  trouble  to 
commence  veritable  respiratory  gymnastics  and  forcing  the 
patient  to  execute  from  time  to  time  a  series  of  large  and  deep 
inspirations.  If  the  pulmonary  congestion  already  exists,  treat 
it  with  repeated  applications  of  dry  cups,  cardiac  tonics  (cam- 
phorated oil,  caffeine,  etc.,)  and  by  all  knowrn  means  of  stimulating 
the  general  condition. 

Late  Intoxication  by  Anesthesia. — This  has  been  particularly 
studied  in  France  by  Tuffier.  If  slight,  question  is  evidenced  by  a 
very  small  and  transient  albuminuria  and  sometimes  by  a  transi- 
tory jaundice ;  if  serious,  by  a  diminution  of  the  quantity  of  urine, 
which  contains  albumen,  urobilin,  bile,  some  acetone,  an  excess  of 
nitrogenous  matter  by  nervous  phenomena  (delirium,  trembling) , 
respiratory  (irregular  dyspnea),  by  vomiting  which  may  assume 
the  aspect  of  vomito  negro.  Generally  these  symptoms  go  on  to 
coma,  and  death  may  follow  on  the  third  to  seventh  day. 

It  has  been  recommended  to  give  glucose  and  alkalies  and 
inhalation  of  oxygen  to  this  condition. 

Retention  of  Urine. — This  is  frequent  and  may  be  treated  by 
catheterization  which  should  be  done  with  a  perfect  aseptic  tech- 
nic  so  as  to  avoid  secondary  infection  and  following  cystitis. 

Abscess  of  the  Wall. — Abscesses  of  the  wall  are  due  to  an 
infection  of  sutures  which  may  be  due  to  any  insufficient  steriliza- 
tion or  more  often  to  contamination  during  the  operation.  It  is 
important  to  warn  the  assistant  to  keep  a  sterilized  compress 
above  the  tray  which  contains  the  suture  material  and  not  to 
touch  the  sutures  more  than  is  absolutely  necessary. 


COMPLICATIONS  OF  CELIOTOMY  327 

These  parietal  abscesses  may  come  on  more  or  less  rapidly 
after  operation.  In  cases  where  non-absorbent  sutures  have  been 
used  it  has  come  on  months  or  even  years  after,  while  the  wound 
had  long  healed  by  first  intention  and  so  perfectly  that  the  ques- 
tion has  arisen  of  a  possible  blood  infection. 

When  the  abscess  is  opened,  it  leaves  a  fistula  which  only  heals 
after  the  elimination  of  the  suture,  the  primary  cause  of  the  trouble. 
This  elimination  of  the  suture  is  often  spontaneous.  It  may  be 
hastened  by  the  curetting  of  the  fistulous  tract  \vith  a  very  fine 
curette  which  brings  out  the  contaminated  stitch. 

In  other  cases,  it  is  necessary  to  produce  a  separation  of  the 
tissues  in  order  to  remove  the  cause  of  trouble.  Cocaine  anesthe- 
sia is  usually  sufficient  for  this  little  search  which  may  be  more 
painful  than  at  first  thought.  With  the  catgut  we  employ  usually 
we  are  able  to  avoid  all  late  fistulas  of  abscesses,  and  in  case  of 
infection,  we  obtain  after  opening  of  the  abscess  a  rapid  cure. 

Pyo-stercoral  Fistulas. — Pyo-stercoral  fistulas  are  produced 
in  cases  where  one  has  been  obliged  to  liberate  adherent  intestine. 
The  suture  of  the  altered  parts  does  not  always  suffice  to  prevent 
the  fistula.  This  often  heals  spontaneously.  In  certain  cases 
the  fistula  persists  and  it  is  necessary  to  have  recourse  to  interven- 
tion to  close  it. 

Urinary  Fistulas. — -These  are  usually  due  to  operative  faults. 
They  may  occur  in  bladder  or  urethra.  When  due  to  sectioning 
of  these  organs,  which  has  passed  unperceived,  a  discharge  of 
pathognomonic  urine  takes  place  immediately  after  the  opera- 
tion. If  the  fistula  is  due  to  stricture  of  the  bladder  or  urethra 
by  a  stitch  or  clamp,  the  discharge  occurs  some  days  after  the 
operation. 

Urinary  fistulas,  with  the  exception  perhaps  of  some  little 
vesical  fistulas,  have  little  tendency  to  spontaneous  cure.  They 
demand  an  intervention  which  is  often  complex;  we  will  have 
occasion  to  refer  again  to  this  point. 

Phlebitis. — Phlebitis  with  the  embolus  which  follows  it  some- 
times constitutes  a  serious  complication  of  abdominal  operations. 
It  results  from  a  slight  infection  in  patients  with  a  defective 
venous  system  (varicose  veins,  venous  enlargements  following  on 
large  abdominal  tumors),  blood  the  coagulability  of  which  is 
increased  (in  patients  with  fibromata,  chronic  affections,  anemia, 


328  ABDOMINAL   CELIOTOMY 

etc.),  and  an  insufficient  circulation  (fatty  and  feeble  heart,  and  an 
atonic  digestive  canal). 

It  has  been  advised,  as  prophylactic  means,  to  relieve  the 
blood  pressure  to  disinfect  this  digestive  tube  and  to  give  citric 
acid.  If  thrombosis  comes  on,  envelop  the  limb  in  wool, 
immobilize  it  and  place  the  foot  in  good  position, 

In  case  of  embolus,  Trendelenburg  advises  the  opening  of  the 
pulmonary  artery  and  the  removal  of  the  clot,  a  practice  which 
one  has  not  often  the  opportunity  to  follow,  and  the  efficacy  of 
which  has  not  yet  been  proved. 

Eventration. — This  may  be  immediate  or  late.  Immediate, 
when  it  comes  on  in  the  day  following  the  removal  of  the  stitches. 
It  is  accompanied  by  the  issue  under  the  dressing  of  loops  of  the 
intestines.  A  curious  point  is  that  this  complication,  in  appear- 
ance very  serious,  is  not,  generally  speaking,  the  point  of  departure 
of  any  other  complication.  We  introduce  the  intestines  and 
close  the  wound  and  the  patient  is  generally  cured.  This  compli- 
cation may  be  avoided  by  using  a  material  which  slowly  absorbs 
(chromicized  catgut),  and  in  cases  of  suture  en  masse,  only 
removing  the  stitches  late  if  the  general  defective  state  of  the 
patient  makes  us  fear  a  delay  in  the  establishment  of  solid  union. 

Late  eventration  is  justifiable  in  an  operation  where  we  wish 
to  reconstitute  a  firm  abdominal  wall. 


CHAPTER  III. 

ABDOMINAL  HYSTERECTOMY. 

Summary. — Abdominal  hysterectomy. — Type  of  procedure. — Various 
procedures  (H.  by  separation,  H.  by  primary  removal  of  the  uterus,  H.  by 
continuous  transverse  section,  H.  by  uterine  hemisection,  H.  total  by  sub- 
peritoneal  decortication  with  primary  opening  of  the  posterior  vaginal  fornix). 
— Indications  and  modifications  of  technic  according  to  the  nature  of  the 
lesions  (inflammation  of  adnexa,  fibromata,  cancer,  prolapse,  puerperal 
infection,  uterine  rupture). 

Fifteen  years  ago  abdominal  hysterectomy  was  the  object  of 
numerous  discussions;  of  controversies  on  the  treatment  of  the 
pedicle  or  stump  after  the  removal  of  the  organ.  Some  advised 
the  fixation  of  the  pedicle  to  the  wound  externally  while  others 
reduce  it  into  the  abdomen ;  others  finally  fixed  it  to .  the  deep 
portion  of  the  anterior  abdominal  wall.  The  relative  value  of 
these  measures  was  largely  discussed  without  any  decision  being 
eventually  arrived  at. 

To-day  abdominal  hysterectomy  has  benefited  by  the  general 
progress  of  the  technic  of  abdominal  operations,  doing  away 
with  pedicles,  isolated  ligatures  of  vessels,  peritonization  of 
intraabdominal  raw  surfaces.  The  operation  has  become  sim- 
plified and  excellent  in  its  immediate  and  remote  results. 

1.  Type  of  Procedure. 

The  patient  having  been  placed  in  the  Trendelenburg  posi- 
tion, the  surgeon  makes  a  median  incision  sufficient  to  allow  him 
to  see  well. 

Having  inserted  lateral  retractors,  or  a  large  sub-pubic  valvu- 
lar retractor,  he  frees  the  pelvic  cavity  by  turning  back  the  intes- 
tines toward  the  diaphragm  and  maintaining  them  there  by  hot 
sterilized  cloth  compresses. 

A  rapid  palpation  determines  the  connections  of  the  pelvic 
organs  and  adhesions  which  they  present,  etc. 

329 


330 


After  making  these  observations  the  operator  brings  the  uterus 
into  the  wound,  drawing  upon  it  with  the  hand  and  using,  in 
case  of  necessity,  toothed  forceps  or  even  in  fibromata,  a  cork- 
screw, and  as  soon  as  the  uterus  is  drawn  to  the  outside,  a  large 


FIG.  292. — Abdominal  hysterectomy.  The  utero-ovarian  vessels  have  been  cut  across 
between  a  ligature  and  pair  of  forceps.  The  blunt  needle,  threaded  with  a  stitch,  takes  up 
the  round  ligament  which  will  be  cut  and  tied. 

compress  is  inserted  behind  it  in  order  to  protect  the  intestine; 
this  has  in  all  probability  been  done  at  the  beginning  of  the  opera- 
tion. The  field  of  operation  is  then  circumscribed  with  many 
other  cloth  compresses,  maintaining  the  intestines  well  confined 


TYPE  OF  PROCEDURE  331 

beneath  them  and  preventing  them  entering  the  pelvis,  which 
accident  may  arise  in  spite  of  the  elevated  position  of  the  pelvis 
as  the  result  of  a  fit  of  coughing  or  effort  of  vomiting,  etc. 

We  now  proceed  to  the  ligature  of  the  right  utero-ovarian 
pedicle.  Xo  do  this,  the  uterus  is  drawn  forward  to  the  left. 
The  operator  seizes  between  his  left  thumb  and  index-finger  the 
utero-ovarian  pedicle,  raises  it  and  passes  below7  it  a  blunt  needle 
(Fig.  293)  threaded  with  No.  1  or  No.  2  catgut.  Tightly  tie  this 
catgut  around  the  infundibulo-pelvic  ligament  just  outside  the 
adnexa. 

A  pair  of  forceps  having  been  placed  a  little  outside  this  liga- 
ture, the  pedicle  is  cut  through  very  close  to  the  forceps.  With 
the  scissors  the  broad  ligament  is  severed  almost  at  the  level  of  the 
round  ligament.  This  segment  of  the  broad  ligament  is  muscular, 
and  preliminary  forcipressure  is  useless  if  applied  to  it.  How- 
ever, note  that  before  cutting  through  the  round  ligament  it  is  of 
advantage  to  enclose  it  in  a  ligature,  because  it  generally  con- 


KIG.  293. — Blunt  needle  (Hartmann).     This  needle  enables  us  to  take  up  the  vessel  on 
the  floor  of  the  excavation  and  on  its  wall  by  reason  of  the  acute  angle  of  the  needle. 

tains  a  little  arteriole  (Fig.  292).  It  is  cut  through  after  having 
first  fixed  a  pair  of  forceps  a  little  internal  to  the  ligature  that 
surrounds  it.  The  same  procedure  is  carried  out  on  the  opposite 
side. 

Of  the  six  arterial  pedicles  of  the  uterus,  four  are  already 
tied.  There  now  remains  only  the  two  uterine  arterial  pedicles. 
They  are,  it  is  true,  the  most  important. 

To  expose  them,  we  unite  with  a  transverse  incision  the  two 
sections  of  the  broad  ligament;  this  incision  passes  along  the 
anterior  face  of  the  uterus  a  little  above  the  floor  of  the  vesico- 
uterine  cul-de-sac.  We  then  separate  the  bladder  in  the  middle 
line  and  on  each  side  the  anterior  fold  of  the  broad  ligaments, 
pressing  the  whole  forward.  The  separation  of  the  bladder  is 
generally  easy  but  it  is  sometimes  necessary  to  use  scissors  in 
order  to  sever  some  rather  firmer  adhesions  along  the  median 
line,  as  to  the  anterior  fold  of  the  broad  ligament,  it  is  very 


332  ABDOMINAL   HYSTERECTOMY 

easily  separated.  This  separation  exposes  the  uterine  pedicles, 
which  are  isolated  with  a  grooved  sound ;  this  isolation  should  be 
done  gently,  in  order  to  avoid  tearing  the  peri-arterial  venous 
plexus,  a  tear  of  little  importance  but  which  may  become  very 


FIG.  294. — Abdominal  hysterectomy.  The  utero-ovarian  pedicles  and  round  liga- 
ments have  been  tied  and  severed ;  the  vesico-uterine  peritoneum  already  cut  through 
has  been  separated  by  ligature  of  the  right  uterine  artery. 

troublesome  and  which  it  is  better  to  avoid.  The  isolated  ped- 
icles are  then  taken  up  with  a  blunt  needle.  One  blunt  needle 
is  of  advantage  in  this  (Fig  293),  being  more  handy  than  the 
other  forms  used,  as  will  be  found  in  all  cases  where  a  ligature 


TYPE  OF  PROCEDURE 


333 


has  to  be  passed  around  a  pedicle  lying  deep  in  a  cavity.  The 
catgut  passed  by  this  needle  is  immediately  tied,  a  pair  of  forceps 
is  placed  a  little  above  the  ligature  and  the  two  uterine  pedicles 
are  cut  through  between  forceps  and  ligature. 


FIG.  295. — Subtotal  abdominal  hysterectomy.     After  removing  a  wedge-shaped  piece 
of  tissue,  the  cervix  is  now  sutured. 

The  detachment  of  the  uterus  now  alone  remains. 

The  stages  of  the  operation  vary  according  as  it  is  desired  to 
do  a  total  hysterectomy  or  to  cut  across  the  uterus  immediately 
above  the  vagina,  and  leaving  behind  the  vaginal  portion  of  the 
cervix.  This  is  generally  known  as  subtotal  hysterectomy. 


334 


ABDOMINAL   HYSTERECTOMY 


In  subtotal  hysterectomy,  the  uterus  is  sectioned  across 
immediately  above  the  insertion  of  the  vagina.  This  section 
is  made  with  the  knife  from  before  backward;  then  the  cervix  is 


FIG.  296. — Subtotal  abdominal  hysterectomy.  After  removal  of  a  wedge-shaped 
piece  of  muscular  tissue,  the  cervix  is  sutured ;  a  continuous  peritoneal  suture,  interrupted 
at  every  fourth  or  fifth  stitch,  buries  the  ligatured  pedicles  and  the  cervix,  thus  securing 
a  complete  peritonization  of  the  parts. 


hollowed  out;  all  these  cut  surfaces  bleed;  if  it  is  only  a  slight 
oozing,  traction  forceps  suffice  to  secure  temporary  hemostasis. 
This  operative  procedure  is  carried  out  in  the  following  manner: 


TYPE  OF  PROCEDURE 


335 


The  uterus  having  been  drawn  upward  and  a  little  backward 
the  anterior  face  of  the  uterus  is  incised  with  the  scalpel  and 
then  the  anterior  portion  of  the  cervix  seized  with  a  pair  of 


FIG.  297. — Total  hysterectomy.  The  separation  of  the  bladder  having  proceeded 
far  enough,  the  vagina  is  opened  anteriorly;  a  pair  of  Museux's  forceps  seizes  the 
anterior  lip  of  the  so-called  buttonhole.  All  that  now  remains  is  to  separate  the  vagina 
from  around  the  cervix. 


forceps  and  the  incision  is  continued  posteriorly^until  the  organ 
is  completely  severed.  As  the  cervix  is  fixed  by  the  forceps, 
it  does  not  fall  back.  Nothing  is  simpler,  once  the^  amputation 


336 


ABDOMINAL   HYSTERECTOMY 


is  concluded,  than  to  place  a  second  pair  of  Museux's  forceps 
on  the  posterior  face,  and  then,  exposing  with  these  two  pairs 
of  forceps  the  upper  portion  of  the  cervix,  to  excise  a  wedge- 
shaped  piece  of  muscular  tissue  and  to  remove  in  its  entirety  the 
intracervical  mucous  membrane.  All  that  remains  finally  is 
two  flaps  of  the  cervix  in  front  and  behind.  This  method  has  the 


/Wctrissc., 


FIG,  298. — Total  hysterectomy.     The  cervix  is  drawn  through  a  buttonhole  made  in 

the  posterior  vaginal  wall. 

advantage  of  creating  two  supple  flaps,  which  adapt  themselves 
easily,  the  one  to  the  other,  for  the  suture  and  of  doing  away  with 
the  sometimes  diseased  endocervical  mucous  membrane.  Three 
catguts  unite  the  anterior  and  posterior  lips  of  the  surface  left 
after  the  section  and  assure  hemostasis  at  the  same  time. 

If  it  is  desired  to  do  total  hysterectomy,  the  separation  of  the 


TYPE  OF  PROCEDURE  337 

bladder  is  carried  on  anteriorly  until  the  anterior  vaginal  wall 
is  reached.  It  is  opened,  and  then  with  a  pair  of  Museux's 
forceps  seize  the  vaginal  lip  of  the  incision  and  complete  the 
disinsertion  of  this  canal  by  a  circular  incision  with  scissors, 
which  work  obliquely,  while  the  uterus  is  drawn  up  and  away 
from  the  side  where  one  is  working  (Fig.  297). 

If  there  are  doubts  as  to  the  situation  of  the  vagina,  wre  may, 
as  Doyen  does,  open  in  the  median  line  posteriorly,  on  the  end  of 
a  pair  of  forceps  introduced  through  the  vulva. 

It  is  then  easy  to  seize  the  cervix  with  a  special  pair  of  forceps 
(Fig.  309)  through  the  buttonhole  made  in  the  posterior  wall  of  the 
vagina,  to  draw7  upon  it,  and  to  disinsert  the  vagina  around  its 
whole  circumference  (Fig.  298). 

The  uterus  having  been  removed,  a  wick  of  iodoform  gauze 
is  introduced  through  the  gaping  opening  of  the  superior  portion 
of  the  vagina  and  which  latter  is  closed  by  a  series  of  catgut  sutures 
which  serve  at  the  same  time  to  stop  the  numerous  bleeding 
points. 

If  it  is  desired  to  do  vaginal  drainage  close  the  lateral  bleeding 
parts  and  leave  open  the  middle  part  of  the  vagina,  and  whatever 
the  operation  performed,  whether  it  be  subtotal  or  total  hysterec- 
tomy, from  that  point  the  end  of  the  operation  is  the  same.  It 
is  necessary  to  cover  the  raw  surfaces  with  peritoneum,  which 
may  be  done  with  a  continuous  suture  of  fine  catgut,  which  buries 
laterally  the  vascular  pedicles,  in  the  middle  the  vaginal  suture 
or  the  uterine  pedicle  according  as  whether  the  cervix  has  been 
removed  in  its  entirety  or  not. 

When  the  operation  is  concluded,  the  floor  of  the  pelvis  pre- 
sents an  absolutely  smooth  surface ;  if  one  has  the  opportunity  to 
study  the  pelvic  cavity  of  a  woman  thus  operated  on  several  weeks 
afterward,  one  is  struck  by  the  complete  absence  of  the  adhesions, 
by  the  regularity  of  the  floor  of  the  pelvis ;  if  it  were  not  for  the 
absence  of  uterus  and  adnexa,  no  abnormality  would  suggest  an 
operation. 

We  will  not  return  to  the  subject  of  drainage  by  abdomen  or 
vagina  or  the  transverse  partitioning  of  the  pelvis  by  suture  of  the 
pelvic  colon  to  the  retro-vesical  peritoneum,  as  we  have  already 
dealt  with  these  questions  in  the  chapter  of  celiotomy  in  general. 


22 


338 


ABDOMINAL   HYSTERECTOMY 


2.  Various  Procedures. 
Hysterectomy  by  Separation. 

With  recognition  of  the  fact  that  the  principal  means  of  fixa- 
tion of  the  uterus  is  its  continuity  with  the  vagina,  J.  L.  Faure 
recommends  commencing  by  the  separation  of  the  uterus  from 
the  vagina  by  incising  it  across  above  its  vaginal  insertions. 
This  division  of  the  cervix  uteri,  this  uterine  separation,  is  carried 


FIG.  299. — Hysterectomy  by  sepa- 
ration. The  uterus  having  been 
drawn  upward  and  forward,  the  scis- 
sors cut  across  the  isthmus  of  the 
uterus. 


FIG.  300. — Hysterectomy  by 
separation.  The  isthmus  has  been 
divided.  The  body  is  only  at- 
tached to  the  cervix  by  an  ante- 
rior strip  of  uterine  tissue. 


out  before  any  other  manipulation,  and  is  the  capital  act  of  the 
operation. 

The  uterus  is  drawn  out  and  turned  over  as  much  as  possible 
on  to  the  pubis.  We  are  then  enabled  to  see  the  pouch  of  Doug- 
las and  the  isthmus  of  the  uterus,  which  is  recognized,  in  general, 
quite  easily  by  the  presence  of  a  constriction  corresponding  to  the 
upper  edge  of  the  utero-sacral  ligaments  below  the  body  of  the 
uterus  which  commences  to  widen  out  above  the  smooth  and 
slightly  "bombe"  cervix. 


339 


If  the  uterus  is  deformed  by  fibromatous  bases,  the  isthmus  is 
less  plainly  seen,  but  it  may  be  recognized  on  palpation.  The 
index-finger,  introduced  so  as  to  lie  on  the  floor  of  the  pouch  of 
Douglas,  between  the  two  utero-sacral  ligaments,  depresses 
anteriorly  the  supple  and  depressible  wall  of  the  vagina.  If  it  is 
carried  upward  toward  the  uterus,  the  finger  soon  feels  the  pro- 
jection of  the  cervix ;  about  2  or  3  cm.  below  this  lies  the  isthmus. 

When  this  is  recognized,  cut  it  across  with  strong  curved,  blunt 
scissors.  Traction  on  the  body  of  the  uterus  makes  the  incision 


FIG.  301. — Hysterectomy  by  separa- 
tion. The  right  hand  having  pressed  in 
the  anterior  peritoneal  covering,  lifts  up 
and  makes  a  pedicle  of  the  broad  ligament. 


FIG.  302. — Hysterectomy  by  separa- 
tion. The  left  hand  seizes  the  broad 
ligament  while  the  right  hand  attaches 
a  pair  of  forceps  to  it  external  to  the 
adnexa. 


gape  and  one  is  enabled  to  see  the  central  cavity  which  serves  as  a 
guide  and  the  division  may  be  continued  without  fear  of  injuring 
the  bladder  (Figs.  299  and  300). 

For  the  rest,  if  one  goes  beyond  the  uterus,  in  the  great 
majority  of  cases,  one  finds  oneself  in  the  vesico-uterine  cul-de- 
sac  or  above  it. 

As  soon  as  the  separation  is  completed  between  the  body  and 
cervix,  draw  the  former  upward;  then  insert  two  or  three  fingers 
of  the  right  hand  into  the  space  which  separates  the  two  segments 


340  ABDOMINAL   HYSTERECTOMY 

of  the  divided  uterus,  pushing  them  from  behind  forward  with 
the  palmar  surface  of  the  hand  upward.  The  extremities  of  the 
fingers  come  into  contact  with  vesico-uterine  cul-de-sac  which  it 
pushes  in.  The  fingers  lie  in  front  of  the  uterus  and  'broad  liga- 
ments, while  the  thumb  is  behind.  In  carrying  the  hand  toward 
the  right,  the  broad  ligament  is  picked  up  between  the  thumb  and 
index-finger  and  a  pedicle  is  thus  prepared.  Nothing  is  simpler 
than  to  isolate  it  by  lifting  it  from  below  upward  as  far  as  its 
pelvic  insertion  external  to  the  adnexa  (Fig.  301). 

With  the  left  hand  seize  the  already  pediculated  broad  liga- 
ment while  the  right  clamps  the  pedicle  that  is  afterward  divided 
with  scissors  (Fig.  302). 


FIG.  303. — Hysterectomy  by  separation.     The  right  broad  ligament  has  been  divided. 
The  uterus  is  tilted  to  the  left   and  a  forceps  holds  the  left  broad  ligament  (Faure). 

The  uterus  is  tilted  toward  the  left  and  the  left  broad  ligament 
exposed.  This  is  pediculated  as  before  and  divided  with  scissors 
(Fig.  303),  and  the  uterine  arteries  are  tied  as  also  other  bleeding 
points,  and  the  operation  terminated  as  usual. 

When  the  uterus  cannot  be  drawn  forward,  the  cervix  is 
divided  in  front,  on  a  level  with  the  vesico-uterine  cul-de-sac.  A 
pair  of  Museux's  forceps  is  fixed  to  the  inferior  portion  of  the 
body  of  the  uterus,  and  then  with  curved  scissors  the  isthmus 
is  denuded  from  in  front  backward.  It  is  then  quite  a  simple 
affair  to  bring  the  interior  portion  of  the  body  of  the  uterus  for- 


VARIOUS  PROCEDURES  341 

ward  and  to  introduce  the  fingers  behind  it,  and  separate  from 
above  upward  the  adhesions  which  fix  it  behind. 

Hysterectomy  by  Primary  Excision  of  the  Uterus. 

This  procedure  was  initiated  byVillar  and  generalized  mainly 
by  Terrier.  The  fundus  of  the  uterus  is  seized  with  traction  for- 
ceps and  a  long  pair  of  Kocher's  forceps  is  placed  from  above 
downward  along  the  border  of  the  uterus  as  far  as  the  level  of  the 


v  ves. 


FIG.  304.  —  Hysterectomy  by  continuous  transverse  division  (Kelly). 


isthmus;  a  second  identical  forceps  is  placed  a  little  more  exter- 
nal, along  the  whole  depth  of  the  broad  ligament,  which  is  divided 
between  the  two  forceps.  A  similar  manipulation  is  carried  out 
on  the  opposite  side.  The  uterus  is  only  attached  now  to  the 
cervix  which  is  divided  at  the  isthmus  after  clamping  and  tying 
the  uterine  arteries. 

In  place  of  the  excised  uterus  is  an  empty  space  where  the 
hand  may  move  with  ease  in  an  endeavor  to  attack  the  adhesions 
on  each  side. 

Hysterectomy  by  Continuous  Transverse  Section. 

Hysterectomy  by  continuous  transverse  section,  carried  out 
and  first  described  by  Pean,  is  best  known  under  the  name  of 


342  ABDOMINAL   HYSTERECTOMY 

H.  A.  Kelly's  operation.  It  consists  in  cutting  successively  the 
tissues  from  one  side  to  the  other,  commencing  with  the  utero- 
ovarian  pedicle,  broad  ligament  of  the  same  side,  uterus,  broad 
ligament  of  the  other  side  and  finishing  with  ligature  and  division 
of  the  second  utero-ovarian  pedicle. 

The  operation  may  be  commenced  to  the  right  or  the  left, 
choosing  the  side  where  the  operation  seems  simple  owing  to  the 
parts  being  more  accessible. 

Draw  the  uterus  to  the  opposite  side,  tie  the  utero-ovarian 
vessels  on  one  side,  and  divide  the  round  ligament ;  then,  turning 
up  the  adnexa,  cut  obliquely  across  the  broad  ligament  as  far  as 
the  cervix. 

The  vesico-uterine  peritoneum,  having  been  in  its  turn  incised, 
and  the  bladder  pressed  forward,  the  uterine  artery  is  exposed 
to  view  and  is  taken  up  on  a  blunt  needle,  very  low  down  and 
near  the  cervix. 

This  is  divided  in  its  turn  with  strong  blunt  scissors  or  scalpel, 
immediately  above  the  insertion  of  the  vagina.  With  traction 
forceps,  seize  the  superior  lip  of  the  incision  which  is  made  to 
gape  and  then  cut  progressively  the  uterine  tissue  under  visual 
control  until  cut  through  in  almost  all  its  substance.  Continuing 
to  draw  gently  on  the  forceps,  one  observes  that  the  uterus,  in 
tilting,  separates  from  the  broad  ligament  of  the  opposite  side; 
the  second  uterine  artery  comes  into  view ;  it  is  tied  and  cut  in  its 
turn  (Fig.  304). 

Continuing  the  tilting  movement,  the  second  broad  ligament 
unfolds  to  our  view,  the  utero-adnexal  mass  only  holds  together 
by  the  round  ligament  and  the  utero-ovarian  pedicle,  which  is 
clamped  and  divided  without  the  least  difficulty. 

If  in  this  operation  it  is  decided  to  do  a  total  hysterectomy,  in 
place  of  dividing  the  cervix,  after  having  tied  the  first  uterine 
artery,  one  proceeds  to  the  separation  of  the  soft  tissues,  close 
up  to  the  uterus,  between  this  organ  and  the  tied  uterine  artery, 
and  continues  until  the  lateral  vaginal  fornix  is  reached.  It  is 
recognized  by  the  difference  in  consistence  of  the  tissues.  It  is 
opened  laterally  with  the  scissors. 

Seize  the  incision  thus  made  with  a  pair  of  forceps,  in  order 
that  it  may  not  fall  back;  then,  attaching  strong  toothed  forceps 
to  the  cervix,  it  is  drawn  upward,  while  the  vagina  is  divided 


VARIOUS  PROCEDURES 


343 


completely   around   it   with   strong   scissors    which   should   not 
deviate  from  uterine  tissue. 

This  disinsertion  having  been  completed,  the  uterine  artery 
on  the  opposite  side  is  tied  and  divided,  and  the  operation  is 
concluded  as  in  subtotal  hysterectomy. 

Hysterectomy  by  Uterine  Hemisection. 

This  procedure  has  been  described  and  carried  out  by  J.  L. 
Faure  who  operates  as  follows :  The  f undus  of  the  uterus  having 
been  seized  with  two  strong  forceps,  both  of  which  are  attached  a 
little  outside  of  the  median  line,  it  is  divided  as  far  as  the  isthmus, 


FIG.  305.  —  Hysterectomy  by 
hemisection.  The  uterus  is  drawn 
upward  by  two  forceps  and  the 
hemisection  is  commenced. 


FIG.  306. — Hysterectomy  by  hemi- 
section. The  right  half  of  the  uterus 
detached  at  the  level  of  the  isthmus  is 
drawn  upward.  Clamping  of  the  left 
half  of  the  uterus  (J.  L.  Faure). 


at  the  level  of  the  vesico-uterine  cul-de-sac.     It  is  very  easy  to 
avoid  all  uterine  hemorrhage,  to  cut  exactly  in  the  middle  line 
wThen  traversing  the  uterine  cavity.     As  soon  as  the  uterine  cavity 
is  opened,  it  is  sterilized  by  the  application  of  a  thermocautery. 
The  uterus  is  thus  divided  into  two  halves  as  far  as  the  isthmus. 


ABDOMINAL   HYSTERECTOMY 


One  of  the  halves  is  taken  up  with  a  traction  forceps  near  the 
isthmus  and  then  with  large  curved  scissors,  it  is  divided  at  this 
level  (Figs.  305  and  306).  Drawing  on  this  half  of  the  uterus  it  is 
made  to  pivot  around  the  insertion  of  the  adnexa.  The  uterine 
vessels  are  approached  internally  and  are  divided  after  having 
been  clamped.  Continuing  to  draw  on  the  laterally  inclined 
half  of  the  uterus,  the  adnexa  are  then  drawn  upon  and  separated 
below.  The  operation  is  concluded  by  the  clamping  and  section 
across  of  the  round  ligament,  and  then  of  the  utero-ovarian 
vessels. 


FIG.  307. — Hysterectomy  by  hemi- 
section.  Turning  down  of  the  right 
half  of  the  uterus.  Clamping  of  the  cor- 
responding broad  ligament  which  will 
now  be  divided. 


FIG.  308. — Total  hysterectomy  by 
hemisection.  Disinsertion  of  the  vagina 
in  a  line  with  the  divided  cervix  on  the 
right  side. 


The  same  manipulations  are  carried  out  on  the  other  side.  In 
short,  each  half  of  the  uterus  is  dealt  with  as  in  the  second  half  of 
the  operation  for  hysterectomy  with  the  continuous  transverse 
section. 

If  it  is  desired  to  do  total  hysterectomy  by  this  method,  the 
vesico-uterine  cul-de-sac  is  incised,[and  the  bladder  pushed  back, 


.    VARIOUS  PROCEDURES  345 

thus  freeing  completely  the  anterior  face  of  the  cervix  and  the 
superior  portion  of  the  vagina.  Then  instead  of  stopping  the 
median  section  on  a  level  with  the  isthmus,  the  incision  is  con- 
tinued right  into  the  vaginal  cavity.  Seizing  one  of  the  halves  of 
the  cervix  with  a  traction  forceps,  it  is  drawn  upward  and  outward, 
the  vagina  is  cut,  stretched,  and  divided  close  against  the  uterine 
tissues  and  one  continues  as  before  (Figs.  307  and  308). 

Total  Hysterectomy  by  Subperitoneal  Decortication  with  Primary  Opening 
of  the  Posterior  Fornix  and  with  Preliminary  Hemostasis. 

This  procedure  owes  its  introduction  to  Doyen  and  reposes  on 
the  rejection  of  all  preventive  hemostasis;  it  is  carried  out  in 
the  following  manner: 

The  surgeon  stands  to  the  left  of  the  patient.  The  uterus  is 
thrown  down  on  the  symphysis.  The  posterior  fornix  of  the 
vagina  is  opened.  This  fornix  is  rendered  prominent  by  the 
preliminary  introduction  of  a  curved  pair  of  forceps  into  the  vag- 
inal cavity.  The  finger  is  introduced  into  the  vaginal  buttonhole, 
the  cervix  is  recognized  and  taken  up  with  a  special  hook.  We 
prefer  forceps  (Fig.  309)  to  Doyen's  instrument.  The  cervix  is 
drawn  upward  and  appears  between  the  edges  of  the  button- 


FIG.  309. — Forceps  to  seize  the  cervix  through  the  buttonhole  in  the  posterior  wall  of  the 

vagina. 

hole  incision  in  the  vagina.  It  is  easy  to  recognize  its  lateral 
attachments  with  the  index-finger  of  the  left  hand.  A  scalpel  or 
scissors  is  employed  to  make  a  division  on  each  side  in  contact 
with  the  uterine  tissue.  Free  the  lower  end  of  the  cervix  from  its 
lateral  attachments  to  the  interior  portion  of  the  broad  ligament. 
It  is  raised  up  immediately  by  traction  of  the  forceps  in  an  upward 
direction. 


346 


ABDOMINAL   HYSTERECTOMY 


The  anterior  fornix,  then  exposed,  is  cut  across  with  scissors 
in  contact  with  the  cervix.  By  drawing  strongly  on  the  forceps, 
the  bladder  may  be  detached  with  the  right  index-finger. 

The  uterus  is  now  only  retained  by  its  lateral  vascular  connec- 
tions. It  suffices  in  order  to  free  it,  to  introduce  the  left  index- 
finger  toward  the  right,  above  the  broad  ligament,  and  then  to  per- 
forate the  vesico-uterine  peritoneum  and  to  proceed  to  the  sepa- 
ration of  the  right  broad  ligament  with  the  finger  bent  like  a  hook. 


FIG.  310. — Hysterectomy  by  subperitoneal  decortication.  The  vagina  having  been 
opened  posteriorly,  is  divided  around  the  cervix  which  is  then  drawn  upward,  detaching 
it  in  this  manner  from  the  bladder  (Doyen). 

This  ligament  is  seized  by  the  assistant  between  thumb  and  index- 
finger  and  divided  between  the  adnexa  and  the  uterus.  The  tumor 
is  then  rapidly  tilted  toward  the  left.  It  strips  itself  of  its  anterior 
serous  envelope  which  is  cut  across  if  it  offers  any  resistance,  then 
of  its  connections  with  the  left  broad  ligament,  and  finally  only 
adheres  by  the  superior  border  of  this  latter.  A  final  cut  with  the 
scissors  frees  the  uterus  which  is  caught  by  an  assistant.  The 
surgeon  then  seizes  the  broad  ligament  of  the  left  side  and 
finally  proceeds  to  the  hemostasis  of  the  broad  ligaments.  Two 
ligatures  on  each  side  secure  this  in  the  simple  cases. 

The  utero-ovarian  pedicles  are  drawn  into  the  vagina  and  the 
peritoneal-vaginal  opening  is  closed  writh  a  purse-string  suture, 
and  where  this  is  impossible  by  a  continuous  one. 


INDICATIONS  FOR  ABDOMINAL   HYSTERECTOMY  347 

3.  Indications  for  Abdominal  Hysterectomy  and  Modifications 
of  Technic  According  to  the  Nature  of  the  Lesions. 

Abdominal  Hysterectomy  for  Inflammatory  Adnexa. 

Technic  in  abdominal  hysterectomy  presents  no  specialty 
in  the  case  of  inflammation  of  the  adnexa.  It  is  important  to 
limit  the  operative  field  when  one  is  dealing  with  suppurative 
lesions  of  the  adnexa.  It  is  in  such  cases  necessary  to  double 
and  triple  the  rampart  of  compresses  which  protect  the  area  of 
operation  from  the  general  peritoneal  cavity.  The  superficial 
already  soiled  compresses  should  be  changed  in  order  to  prevent 
infection  going  through  to  the  deeper  compresses  and  then  to  the 
intestines. 

The  existence  of  adhesions,  although  it  does  not  interfere 
with  the  course  of  the  operation,  may  complicate  its  execution. 
The  freeing  of  these  adhesions  is  more  or  less  easy  according  to 
the  case.  Commence  with  the  least  resistant.  Generally  the 
finger  may  detach  these ;  one  should  be  careful  to  tear  them  from 
the  organ  about  to  be  removed ;  this  is  the  best  means  of  avoiding 
lesions  of  the  adherent  intestine.  When  the  adhesions  are  too 
tight,  dissect  them  with  a  scalpel  or  scissors,  taking  care  to  cut 
always  from  the  side  of  the  organ  to  be  removed.  We  have  seen 
how  the  intestine  may  be  injured  in  these  manipulations  and  have 
indicated  the  course  to  follow  in  such  cases. 

With  patience  and  method  we  arrive  at  a  successful  issue 
even  in  those  cases  which  seemed  impossible  at  first. 

If  the  adhesions  are  so  numerous  that  they  render  the  pelvic 
organs  unrecognizable,  concealed  by  adherent  great  omentum 
and  intestine,  in  order  to  find  our  whereabouts  we  must  first 
look  for  the  body  of  the  uterus.  To  do  this,  commence  by 
separating  the  parts  in  the  median  line  behind  the  pubis;  one 
then  comes  across  the  posterior  face  of  the  bladder;  in  liberating 
it  little  by  little,  one  infallibly  finds  oneself  in  the  vesico-uterine 
cul-de-sac,  and  then  to  the  anterior  face  of  the  uterus.  Little 
by  little  we  free  the  fundus  and  then  the  posterior  face  of  that 
organ.  This  having  been  done,  we  are  masters  of  the  situation, 
and  it  is  easy  to  free  the  adnexa.  All  that  now  remains  is  the 
hysterectomy,  following  the  method  we  have  related. 


348  ABDOMINAL   HYSTERECTOMY 

The  special  procedure  we  have  described  may  sometimes  be 
of  service,  in  particular  that  of  continuous  transverse  section, 
which  is  specially  indicated  in  those  cases  of  inflammation  of  the 
adnexa  where  the  parts  are  easily  accessible  on  one  side  but  not 
on  the  other.  Commence  the  operation  on  the  easily  accessible 
side  and  one  finds  oneself  admirably  situated  to  attack  the  very 
adherent  adnexa  from  below  upward  and  from  within  outward 
on  the  opposite  side. 

If  the  cervix  is  almost  normal,  it  suffices  to  hollow  it  out  and 
do  a  subtotal  hysterectomy;  if  on  the  contrary  it  is  very  diseased, 
it  is  illogical  to  leave  it,  and  we  should  do  a  total  hysterectomy. 
This  is  even  indicated  when  the  raw  surfaces  of  the  pelvis  cannot 
be  clothed  with  peritoneum  and  if  possible  to  terminate  the 
operation  by  a  partitioning  of  the  pelvis  above  the  area  drained 
by  the  vagina. 

Recently  Beuttner,  after  removing  the  diseased  tubes,  seeks  a  more  con- 
servative operation.1  He  cuts  a  wedge  from  the  fundus,  preserving  the 
round  ligaments  with  care.  These  incisions  are  prolonged  on  to  the  anterior 
and  posterior  surfaces  of  the  broad  ligaments.  After  having  made  in 
the  median  line  a  hemisection  of  the  wedge  already  cut,  he  seizes  one  of  the 
halves  of  the  fundus  of  the  uterus  with  a  pair  of  Museux's  forceps  and 
detaches  it  with  scissors. 


FIG.  311. — Removal  of  the  tubes  with  partial  preservation  of  the  uterus  and  ovaries 
(the  dotted  line  indicates  the  incision). 

Having  reached  the  cornua  of  the  uterus,  he  cuts  and  clamps  the  uterine 
artery  and  its  branches,  excises  the  diseased  tube  and  if  necessary  on  one  side, 
the  tube  and  ovary.  He  concludes  the  excision  by  ligature  of  the  infundi- 
bulo-pelvic  ligament.  Similar  manipulations  are  carried  out  on  the  opposite 
side. 

The  uterine  wound  is  closed  by  a  deep  musculo-mucous-membrane 
catgut  suture  and  then  a  second  sero-serous  suture  and  if  need  be  a  third 
one. 

1  Aubert,  Concerning  the  Extirpation  of  Bilateral  Adnexa  with  Transverse  Exci- 
sion of  the  Uterus  by  Beuttner's  Procedure.  Revue  medicate  de  la  Suisse  romonde,1909, 
p.  78. 


INDICATIONS  FOR  ABDOMINAL  HYSTERECTOMY  349 

The  operation  being  terminated,  the  surgeon  finds  himself  in  presence  of 
a  little  uterus  accompanied  by  an  ovary  and  some  fragments  of  the  one  or 
both  ovaries  which  have  been  preserved;  the  round  ligaments  still  remain, 
the  relationship  of  the  bladder  and  uterus  have  not  been  in  any  way  changed, 
and  the  broad  ligaments  have  only  been  sacrificed  along  a  very  limited  extent. 
The  menstrual" function  can  go  on  and  the  patient  may  not  regard  herself  as 
deformed. 


FIG.  312. — Operation  finished. 

As  far  as  possible  the  uterine  suture  is  covered  with  peritoneum  and  if 
need  be  it  may  be  covered  over  with  the  loop  of  the  sigmoid  or  even  one  may 
be  forced  to  do  an  anterior  abdominal  hysteropexy  on  the  posterior  face  of  the 
uterus. 

Results. — The  mortality  from  abdominal  hysterectomy  is  at 
present  very  low  and  is  always  becoming  less. 

Our  first  results  show  four  deaths  for  104  operations  or  3.35 
per  cent. ;  our  second  results  showed  two  deaths  in  139  cases 
or  1.43  per  cent.  If  the  lesions  present  degress  different  of 
seriousness  on  each  side,  we  reestablish  one  of  the  broad  liga- 
ments following  our  general  method  and  confine  ourselves  to 
partitioning  off  the  opposite  side  of  the  pelvis.  It  suffices  after 
having  closed  the  broad  ligament  on  the  less  diseased  side  with  a 
continuous  catgut  suture,  to  place  a  drain  in  the  vagina,  the 
extremity  of  which  lies  in  contact  with  the  raw  surfaces  on  the 
opposite  side,  then,  taking  up  the  needle  again,  we  continue  the 
suture  by  uniting  the  recto-vesical  peritoneum  to  the  anterior 
face  of  the  rectum,  and  then  to  the  pelvic  colon  until  all  the  raw 
surfaces  have  disappeared  from  view  under  the  suture. 

The  immediate  results  are  excellent.  The  remote  results  are 
none  the  less  satisfactory.  We  will  return  to  this  question  when 
we  deal  with  treatment  of  inflammation  of  the  adnexa. 

Abdominal  Hysterectomy  for  Fibroma. 

In  the  instance  of  fibroma,  the  execution  of  abdominal  hys- 
terectomy presents  a  certain  number  of  peculiarities. 


350  ABDOMINAL   HYSTERECTOMY 

Opening  of  the  Abdomen. — The  abdominal  wall  should  be 
opened  with  caution.  Its  too  rapid  division  may  injure  the 
fibroma  and  opens  one  of  the  great  venous  sinuses  which  spread 
about  its  surface ;  it  is  a  complication  of  no  great  importance,  but 
which  nevertheless  may  give  rise  to  a  very  troublesome  but  non- 
dangerous  oozing. 

A  prudent  incision  enables  us  to  escape  wounding  the  bladder, 
to  wrhich  one  is  exposed  in  cases  \vhere  the  organ  has  been  drawn 
toward  the  umbilicus  by  a  fibroma  developed  below  the  vesico- 
uterine  cul-de-sac.  We  must  fear  a  similar  ascension  of  the  blad- 
der, when,  after  incision  of  the  musculo-aponeurotic  layer,  one 
comes  into  contact  with  a  thick  fatty  layer,  wrhich  leads  one  to 
think  of  that  which  lines  the  bladder  in  front.  In  such  a  case,  it 
is  recommended  to  work  toward  the  umbilicus  in  order  to  open 
the  peritoneum  above  the  dangerous  zone. 

Extraction  of  the  Fibroma. — When  the  abdomen  is  open, 
rapidly  explore  the  tumor  in  order  to  ascertain  its  connections  and 
mobility,  increasing,  if  necessary,  the  incision  made  in  the  wall. 
Then  draw  the  fibroma  to  the  exterior  with  the  hand  or  with  a 
large  pair  of  Museux's  forceps,  a  proceeding  of  no  difficulty. 


FIG.  313. — Large  pair  of  Museux's  forceps. 

In  certain  cases  the  extraction  of  the  fibroma  may  be  very 
difficult.  We  should  then  use  a  corkscrew  (Fig.  314)  which  is 
solidly  implanted  into  the  tumor,  taking  care  not  to  enter  the 
neighboring  parts  of  the  pubis,  but  of  forcing  it  into  the  parts 
as  high  as  possible,  in  such  a  way  as  to  be  able  to  easily  draw  the 
superior  pole  of  the  fibroma  out  of  the  w^ound,  and  to  tilt  it  out 
of  the  abdomen  without  running  the  risk  of  struggling  against 
the  opposition  of  the  symphysis.  Strong  traction  on  this  cork- 
screw suffices  to  bring  the  fibroma  out  of  the  pelvis  at  first,  and 


INDICATIONS  FOR  ABDOMINAL  HYSTERECTOMY 


351 


the  abdomen  afterward.  If  it  resists  all  our  efforts,  we  may 
have  recourse  to  morcellement,  enucleating  from  their  site  one 
or  -two  fibromatous  masses.  Traction  forceps  close  the  lips  of 
these  cavities  emptied  of  their  contents  and  the  uterus  thus 
reduced  in  size  is  extracted  with  ease. 

For  enormous  tumors,  A.  Reverdin's  suspension  apparatus 
may  be  useful  (Fig.  315) ;  having  raised  the  tumor,  it  permits  of 
manipulations  round  about  it  and  the  successive  stages  of  the 
operation  being  easily  carried  out.  It  is  useless  to  use  the  special 


\ 


FIG.  314. — Corkscrew  (Doyen). 


FIG.  315. — Reverdin's  pulley. 


forceps  devised  by  this  surgeon ;  it  suffices  to  hook  the  suspension 
apparatus  to  the  corkscrew  firmly  fixed  in  the  fibroma. 

The  ligature  of  the  different  vascular  pedicles  presents  no 
special  difficulty. 

Total  or  Subtotal  Hysterectomy.— Should  we  do  total  or 
subtotal  hysterectomy?  Richelot  has  insisted  on  the  removal  of 
the  organ  in  its  entirety,  body  and  cervix,  in  order  to  entirely 
avoid  the  secondary  cancerous  degenerations  which  may  occur 


352  ABDOMINAL   HYSTERECTOMY 

in  the  preserved  cervical  stump.  It  is  quite  certain  that  this 
argument  has  its  value,  as  quite  a  number  of  such  observations 
have  been  published.  It  loses  much  of  its  importance,  if  one 
takes  care,  as  we  advise,  to  hollow  out  the  cervical  stump  as  far 
as  its  extremity  and  of  extirpating  the  whole  of  the  intracervical 
mucous  membrane.  It  is  certain  that  one  thus  avoids  degenera- 
tions of  the  vaginal  face  of  the  cervix;  but  the  total  removal  of 
the  cervix  does  not  prevent  the  development  of  a  secondary 
carcinoma  with  vaginal  cicatrix,  as  the  observations  of  Pierre 
Duval,  Temoin,  and  Bazy  and  others  prove. 

We  believe  that  the  line  of  conduct  is  dictated  by  the  state 
of  the  cervix.  If  it  contains  fibromatous  nodules,  if  there  is  a 
suspicion  of  intracervical  carcinoma,  total  hysterectomy  is  the 
course  to  take.  If,  on  the  contrary,  the  cervix  is  absolutely 
healthy,  we  prefer  to  do  the  subtotal,  which  has  the  advantage  of 
being  a  little  simpler  and  more  rapid,  which  is  of  importance 
when  the  operation  has  lasted  a  certain  time. 

Hysterectomy  for  Included  Fibroids. — If  we  have  to  deal  with 
an  included  fibroid  in  one  of  the  broad  ligaments,  the  operation 
has  certain  peculiarities. 

The  inclusion  having  been  recognized,  a  matter  of  ease,  as  the 
peritoneum  which  covers  over  the  tumor  forms  a  mobile  layer  on 
its  surface,  we  commence  by  cutting  the  utero-ovarian  pedicle  at 
the  level  of  the  infundibulo-pelvic  ligament;  then  two  curved 
incisions  are  made  in  this  pedicle,  crossing  the  anterior  and 
posterior  faces  of  the  tumor  and  attaining  the  body  of  the  uterus. 

We  thus  fix  the  limits  on  the  fibroma  itself,  of  a  peritoneal 
collarette  which  is  separated  with  care  in  order  to  free  the  fibroma. 
This  enucleation  of  the  included  part  should  be  done  with  the 
greatest  care  and  extra  care  should  be  taken  on  arriving  at  the 
base  of  the  ligament. 

At  this  level  one  is  exposed  to  the  danger  of  wounding  the 
ureter;  this  may  be  avoided  if  one  keeps  constantly  in  immediate 
contact  with  the  tumor.  This  method  of  procedure  has  also  the 
advantage  of  not  exposing  the  operator  to  the  risk  of  losing  him- 
self in  bad  planes  of  cleavage  and  of  avoiding  wounds  of  the  other 
organs  in  the  neighborhood  of  the  tumor,  of  large  vessels  or  even 
of  the  pelvic  colon  or  cecum,  wrhen  the  fibroma,  lifting  up  the 
peritoneum  and  unfolding  the  mesenteries,  comes  into  the  neigh- 


INDICATIONS  FOR  ABDOMINAL  HYSTERECTOMY  353 

borhood  of  the  large  intestine.  The  included  masses  having 
been  enucleated,  the  operation  is  concluded  with  an  ordinary 
hysterectomy. 

Hysterectomy  for  Gangrenous  Fibromata. — Technic  is  in 
such  cases  a  little  special. 

Commence  by  removing  as  much  as  possible  of  the  tumor  by 
the  vagina  and  fill  the  uterine  cavity  afterward  with  iodoform 
gauze.  Then  suture  the  cervix,  and  do  a  total  hysterectomy  by 
the  abdomen  without  incision  of  the  uterus,  and  without  morcella- 
tion,  cutting  across  the  vagina  between  two  curved  forceps; 
Kronig  in  fourteen  operated  cases  had  thirteen  cures. 

Rochard1  advises  a  similar  technic;  he  does  a  colpo-hysterec- 


FIG.  316. — Curved  forceps. 


tomy  and  divides  the  vagina  after  having  attached  to  it  some 
curved  forceps,  thus  doing  the  hysterectomy  in  an  isolated  space 
as  Goullioud  has  done  since  1896.  The  important  point  is  to 
avoid  all  discharge  of  hemorrhagic  fluids  in  the  neighborhood  of 
the  wound. 

Conservative  Operations. — Latterly  gynecologists  have  car- 
ried out  conservative  operations. 

They  first  preserved  one  or  two  ovaries,  when  they  were 
healthy.  It  was  found  sufficient  instead  of  tying  the  utero- 
ovarian  artery  at  the  level  of  the  infundibulo-pelvic  ligament  to  tie 
internal  to  the  ovary,  simply  excising  the  tube  with  the  uterus. 

Zweifel  goes  further.2  He  amputates  as  high  as  the  tumor 
permits  and  reestablishes  the  cavity  of  the  uterus  preserving  the 
ovaries  at  the  same  time  so  as  to  obtain  a  persistence  of  menstrua- 

1  Rochard,  Removal  of  the  Uterus  in  an  Isolated  Area  in  Certain  Cases  of  Gangrenous 
Fibromata.     Bull,  el  Mem.  de  la  Soc.  de  Chir.,  Paris,  1904,  p.  778. 

2  Frankenstein,  Ueber  die  Bedeutung  der  Resectio  Uteri  bei  Myoma  zur  Erhaltung  der 
Menstruation  nach  der  Operation.     Arch,  fur  Gyn.,  Berlin,  1907,  T.  83,  p.  477. 

23 


354  ABDOMINAL   HYSTERECTOMY 

tion.  To  preserve  a  sufficient  arterial  supply  for  the  ovary,  we 
must  take  care  of  the  important  branch  it  receives  from  the 
uterine  artery,  and  leave  a  layer  of  uterine  tissue  around  it. 
Remove  the  portion  of  the  uterus  containing  the  fibroids,  and  tie 
the  vessels  that  bleed;  then  suture  the  pedicle  in  two  layers, 
burying  the  first  row  of  sutures  under  a  sero-serous  suture,  which 
at  the  same  time  draws  the  pedicles  of  the  adnexa  in  contact  with 
that  which  remains  of  the  uterus. 

In  more  than  one-half  of  the  cases  menstruation  is  preserved. 

The  conservative  operation,  par  excellence,  is  myomectomy1 
which  may  be  carried  out  in  two  different  conditions,  viz.,  for 
pediculated  myomata  or  interstitial  myomata. 

The  removal  of  pediculated  myomata  is  of  the  simplest  descrip- 
tion. It  consists  in  division  of  the  pedicle,  tying  vessels  if  any, 
and  suturing  \vith  catgut  the  little  uterine  wound  resulting  from 
the  intervention.  The  only  difficulties  likely  to  be  met  with  are 
those  of  frequent  enough  adhesions  to  omentum  and  intestine. 
The  simplest  thing  to  do  is  to  commence  by  division  of  the  pedicle, 
and  then  attacking  the  adhesions,  tying  and  resecting  the  omen- 
tum, freeing  the  intestine  or  even  leaving  some  of  the  tumor  tissue 
attached  to  the  intestine  if  the  adhesion  is  very  intimate. 

When  we  have  to  deal  with  interstitial  myomata  wre  incise  the 
cortex  of  the  uterus  at  the  level  of  the  myoma  and  just  as  far  as 
the  capsule  that  surrounds  the  latter.  With  a  blunt  instrument 
such  as  a  pair  of  curved  scissors  or  a  special  spatula,  the  tumor 
is  liberated  from  the  cortex  that  surrounds  it.  If  there  are 
several  myomata  close  together,  they  may  be  removed  by  the 
same  incision. 

It  has  been  advised  in  cases  of  large  tumors  to  make  an 
elliptical  incision;  if  one  has  recourse  to  this  incision  we  must 
take  care  as  Kelly  and  Cullen  advise  not  to  remove  too  great  an 
extent  of  the  uterine  cortex  as  this  retracts  after  the  removal  of 
the  tumor  and  union  may  then  be  difficult.  It  is  better  to  be 
satisfied  with  the  simple  incision;  free  if  necessary  to  resect  the 
exuberant  portion  of  the  uterine  flaps. 

As  much  as  possible  during  enucleation  one  should  avoid  the 
opening  of  the  cavity  of  the  uterus  and  to  do  so  one  must  be 

1  Loubet,  Enucleation  of  Uterine  Fibromata  by  Abdominal  Route,  Th.  de  Paris,  1901— 
1902,  No.  319.     Kelly  and  Cullen,  Myomata  of  the  Uterus,  Phila.,  1909. 


INDICATIONS  FOR  ABDOMINAL  HYSTERECTOMY 

careful  to  remain  in  close  contact  with  the  tumor.  If  by  mis- 
chance it  is  opened,  dilate  the  cervix  and  leave  a  drain  for 
several  days  in  its  interior. 


FIG.  317. — The  uterine  tissue  has  been  incised  as  far  as  the  shell  of  the  fibroma;  a  forceps 
draws  upon  the  latter  and  it  is  isolated  with  curved  scissors. 

Once  the  enucleation  is  finished,  suture  the  wound  in  layers 
with  some  catguts  which  pass  right  into  the  substance  of  the 
uterine  tissue,  taking  care  to  get  good  apposition  of  the  parts,  in 
such  a  manner  as  to  leave  no  virtual  cavity  where  fluids  may 
collect. 

If  there  are  several  myomas,  multiple  uterine  incisions  may  be 
required  and  proceed  if  possible  from  the  cavity  of  the  principal 
myoma  into  those  of  less  importance  so  as  to  have  merely  one 
uterine  wound  to  suture. 

We  cannot  yet  appreciate  the  value  of  these  conservative 
operations  and  if  we  face  the  usually  excellent  results  of  hyster- 


356 


ABDOMINAL   HYSTERECTOMY 


FIG.  318. — Passage  of  buried  catgut  suture  uniting  the  walls  of  the  capsule. 


FIG.  319. — Second  layer  of  sutures. 


INDICATIONS  FOR  ABDOMINAL  HYSTERECTOMY  357 

ectomy,  we  are  a  little  tempted  to  recede  from  this  position  and 
we  certainly  prefer  the  complete  operation  which  places  the 
patient  in  a  position  of  having  to  fear  no  recurrence  and  no  more 
pain  from  a  possible  lesion  of  the  adnexa.  Our  average  mor- 
tality for  abdominal  operations  on  fibromas  is  4.1  to  100,  i.e., 
11  deaths  in  268  cases. 


Abdominal  Hysterectomy  for  Cancer  of  the  Uterus. 

The  first  surgeon  to  deliberately  practice  the  excision  of  the 
uterus  for  cancer  by  the  abdominal  route  was  Freund  on  January 
30,  1878.  This  intervention  was  rapidly  followed  by  a  series  of 
others,  but  its  mortality1  was  so  great  that  Freund's  operation 
was  abandoned  for  vaginal  hysterectomy  which  was  advocated 
by  Czerny  in  1880.  The  immediate  results  of  this  operation  were 
incontestably  better  but  the  remote  more  mediocre. 

As  the  technic  of  celiotomy  became  better  return  to  the 
abdominal  route  became  rapid,  and  as  a  result  the  immediate 
prognosis  became  better  and  permitted  a  much  more  extended 
removal  than  by  the  vaginal  route.  By  the  abdomen  it  was 
possible  to  do  an  extensive  excision  of  the  cancer.  With  this  new 
technic  are  associated  the  names  of  Mackenrodt,  Riess,  Rumpf, 
Clark,  Werder  and  Wertheim,  etc.  More  and  more  extensive 
operations  were  advised,  with  the  purpose  of  removing  at  one 
and  the  same  time  the  periuterine  cellular  tissue  and  the  glands 
receiving  the  efferent  lymphatics  from  the  uterus.  The  congress 
in  Rome  in  1902  marked  the  apogee  of  these  attempts.  It  wTas 
at  this  meeting  that  Jonesco  advised  preliminary  ligature  of  the 
hypogastric  artery  and  the  "lumbar-ilio-pelvic  hollowing  out" 
extirpating  all  the  cellulo-fatty  tissue  of  the  pelvis,  iliac  fossae, 
and  interior  lumbar  regions  w^ith  the  vessels  and  lymphatics  they 
contain.  About  the  same  time  Franklin  H.  Martin  in  America 
advised  the  partial  excision  of  the  bladder  with  implantation  of 
the  ureters  in  the  rectum;  Sampson  advised  the  systematic 
excision  of  the  ureters  with  reimplantation  of  their  upper  end 
into  a  higher  point  on  the  bladder  wall. 

1  Ahlfed  in  1881  found  72  deaths  in  100  cases  done  by  Freund;  Gusserow  found  106 
deaths  in  148  cases,  71.6,  per  100. 


358  ABDOMINAL   HYSTERECTOMY 

These  operations  are  often  excessive  and  have  to  a  certain 
extent  been  abandoned.  In  particular  the  systematic  search  for 
all  the  invaded  glands  has  been  abandoned,  as  anatomo-patho- 
logical  researches  show  that  this  removal  was  most  often  useless 
or  impossible. 

In  order  to  establish  it  it  suffices  to  recall  what  researches 
have  established  in  the  last  few  years.  We  will  study  from  this 
point  of  view  the  cancers  of  the  body  and  the  cervix  separately, 
because  from  the  points  of  view  of  extension  to  glands  there  is 
a  great  distinction  bet\veen  the  two. 

In  thirty-four  cases  of  cancers  of  the  body  of  the  uterus,  Kronig 
found  only  five  cases  of  glandular  enlargement;  in  one  case  the 
inguinal  glands,  two  cases  the  iliac  glands,  and  two  cases  the 
lumbar  glands.  In  four  of  these  cases  the  uterine  cancer  had 
gone  beyond  the  limits  of  operation  and  in  the  fifth  a  cancer  of 
the  ovary  had  previously  been  removed. 

In  consequence  in  all  cases  of  cancer  of  the  uterus  which  are 
capable  of  extirpation  there  was  no  glandular  enlargement. 
The  conclusion  to  draw  from  these  observations  is  that  it  is  not 
necessary  to  search  for  the  glands  in  cancer  of  the  body  of  the 
uterus. 

In  cancer  of  the  cervix  the  invasion  of  the  glands  is,  on  the 
contrary,  much  more  important.  Schauta  in  fifty  postmortem 
examinations  of  women,  who  died  from  cancer  of  the  cervix, 
found  thirty- two  cases  of  infected  glands,  being  64  per  cent,  of 
the  cases.  The  search  for  glands  seems  a  priori  to  be  indi- 
cated. But  if  we  look  for  the  situation  of  these  glands  we  will 
see  that  in  the  greatest  number  of  cases  of  infected  glands  we 
find  aortic  as  well  as  pelvic  glands  may  be  in  a  state  of  isolated 
enlargement  or  degenerated.  In  13  per  cent,  of  cases  only  the 
cancerous  degeneration  is  limited  to  the  pelvic  glands,  the  only 
ones  that  the  surgeon  is  able  to  attack  and  then  not  always. 

It  may  be  objected  that  these  statistics  have  been  made  of 
cases  where  the  patients'  died  of  their  cancer,  thus  being  in  a 
different  condition  to  those  for  whom  the  operation  is  a  matter 
of  discussion.  Let  us  then  proceed  to  the  examination  of  those 
who  succumbed  to  surgical  intervention.  Schauta  in  ten  women 
examined  found  only  two  with  cancerous  glands;  Oehlecker 
in  seven  cases  found  two.  It  is  true  that  Kronig  in  eighteen 


INDICATIONS  FOR  ABDOMINAL  HYSTERECTOMY  359 

operative  cases  found  nine  cases  of  glands ;  but  it  must  be  added 
that  Kronig  attempted  the  operation  on  many  cases  that  by 
others  would  be  regarded  as  inoperable  by  reason  of  the  obvious 
extension  beyond  the  uterus. 

KundraJ;,  who  studied  conscientiously  the  question  of  glandu- 
lar propagation  in  Wertheim's  clinic,  found  in  80  cases  54  with 
ganglionic  invasion,  about  59  per  cent.  In  26  cases  there  were 
infected  glands  but  these  glands  were  only  capable  of  extirpation 
in  13  per  cent,  of  cases.  We  therefore  find  a  figure  about  the 
same  as  that  of  Schauta. 

Does  this  figure  of  13  per  cent,  of  glandular  degenerations, 
capable  of  being  operated  on,  authorize  the  systematic  removal  of 
glands  and  to  expose  the  patients  to  a  research  which  incontest- 
ably  aggravate  the  immediate  operative  prognosis  ?  We  do  not 
believe  it.  We  are  supported  in  our  nonbelief  by  the  results  of 
the  anatomo-pathological  researches  of  Oehlecker,  Rosthorn, 
Kromer,  Cullen  and  Sampson,  who  show  that  the  size  of  the 
tumors,  the  only  factor  revealed  during  a  celiotomy,  is  not  a 
certain  index  of  a  cancerous  degeneration.  Large  glands  may 
be  noticed  in  women  and  they  are  merely  inflamed,  while 
quite  small  ones  may  be  degenerated.  If  one  wished  to  be  sure 
of  removing  all  the  infected  glands,  one  should  remove  the  whole 
glandular  chain,  which  is  of  course  impossible. 

Is  failure  the  result  of  the  abdominal  operation  ?  Not  in 
the  least.  The  study  of  recurrences  after  old  operations  shows 
us  that  the  mischief  reappears  at  the  level  of  the  cicatrix  in  the 
immense  majority  of  cases.  This  agrees  with  the  facts  deter- 
mined by  Kundrat  who,  in  160  cases  operated  by  Wertheim, 
found  the  parametrium  invaded  in  55  per  cent.;  with  those  of 
Brunet  who,  in  72  per  cent,  of  cases  where  the  parametrium  was 
clinically  and  macroscopically  free,  nevertheless  found  in  72  per 
cent,  of  these  cases  cancerous  infiltrations;  the  researches  of 
Pankow,  who,  in  60  cases  operated  by  Kronig,  found  the  para- 
metrium affected  in  68.2  per  cent.,  and  finally  Sampson  in  a  study 
of  Kelly's  cases  found  the  parametrium  invaded  in  20  out  of  27 


cases.1 


Another  interesting  anatomo-pathological  point,  well  exposed 

1  Sampson,  A  Careful  Study  of  the  Parametrium  in  27  Cases  of  Carcinoma  Ccrvicis 
Uteri  and  Its  Clinical  Significance.     Am.  Jour.  ofObst.,  New  York,  Oct.,  1906,  p.  433. 


360  ABDOMINAL   HYSTERECTOMY 

by  Brunei's1  examinations  on  Mackenrodt's  cases  and  by  Assereto2 
on  Doderlein's,  is  that  in  a  certain  number  of  cases  there  exists 
an  invasion  of  the  vaginal  wall  by  the  cancer,  and  yet  there  is  no 
change  in.  the  corresponding  mucous  membrane.  We  have  had 
occasion  to  make  the  same  observations. 

The  abdominal  operation  by  permitting  the  extensive  excision 
of  the  vagina  and  parametrium  exhibits  even  in  the  absence  of  a 
glandular  extirpation,  an  incontestable  superiority  over  vaginal 
hysterectomy  and  as  such  merits  substitution  for  the  latter. 

Indications. — All  cases  of  cancer  of  the  uterus  do  not  justify 
an  abdominal  operation  and  one  is  obliged  to  limit  oneself  to  a 
purely  palliative  line  of  treatment.  In  order  to  present  the 
indication  of  so-called  radical  operation,  it  is  necessary  to  do  a 
certain  number  of  exploratory  examinations  by  digital  vaginal 
examination,  digital  rectal  examination,  and  the  cystoscope. 

One  should  not  operate  when  the  vaginal  examination  shows 
an  extensive  invasion  of  the  vagina,  in  particular  if  its  anterior 
wall  is  in  contact  with  the  bladder,  or  perhaps  an  infiltration 
en  masse  of  the  broad  ligaments"  extending  to  their  external 
third.  We  confine  ourselves  to  a  palliative  treatment  when  the 
rectal  examination  shows  a  beaded  induration  in  the  utero- 
sacral  folds  or  the  presence  of  enlarged  presacral  glands.  The 
cystoscopic  examination  of  the  bladder  should  always  be  carried 
out.  It  is  evident  that  direct  invasion  of  the  bladder  should  arrest 
the  surgeon.  The  same  may  be  said  of  certain  lesions  which, 
according  to  Hannes,  would  indicate  the  partial  invasion  of  the 
vesical  coats.  A  prominence  of  the  trigone  which  could  not  be 
explained  otherwise  than  by  a  mechanical  cause  (forcing  back 
of  the  bladder  by  a  large  intravaginal  mushroom  growth  or  by  a 
strongly  anteflexed  uterus)  or  by  folds  or  bullous  edema  of  the 
mucous  membrane.3  According  to  Clark,  the  obliteration  of 
a  ureter  would  have  great  diagnostic  value,  as  purely  inflamma- 
tory infiltrations  of  the  broad  ligaments  never  lead  to  the  arrest 
of  the  passage  of  urine. 

1  Ergbnisse   der  abdominalen     Radikaloperatien  des  Gebarmutter-scheidegkrebies 
mittels  Laparotomia  hypogastrica.     Zeitschr.f.  Geb.,  Stuttgart,  1905,  T.  LVI,  p.  1. 

2  Assereto  (L.),  La  propagazione  del  carcinoma  del  collo  uterino  al  tessuto  paravagi- 
nale.     Annali  di  obstetricia  e  ginecologia,  Milano,  1907. 

3  A  bulging  like  a  bowel  of  the  vescial  mucous  membrane  with  production  of  papil- 
lomatous  nodules  has  a  great  importance  (Scheib) ;  on  the  contrary,  a  bullous  edema, 
according  to  unpublished  researches  of  our  interne,  is  without  value. 


INDICATIONS  FOR  ABDOMINAL  HYSTERECTOMY  361 

The  Operative  Treatment. — Is  there  any  preoperative  treat- 
ment ?  Some  gynecologists  have  advised  a  curettage  of  the 
cancer  8  to  10  days  before  the  hysterectomy. 

This  practice  has  been  in  the  main  abandoned.  It  is  well 
to  do  a  curettage  followed  by  cauterization  before  removing  the 
uterus,  but  it  is  done  at  the  same  sitting.  The  preliminary 
curettage  has,  however,  its  uses  in  certain  cases. 

If  a  woman  is  very  anemic  as  the  result  of  continuous  hemor- 
rhages, curette  and  cauterize  her  cancer,  under  anesthesia  or 
after  a  short  anesthesia  of  ethyl-chloride.  This  curettage  fol- 
lowed by  tamponing  with  iodoform  gauze  arrests  the  hemor- 
rhage and  enables  us  to  tone  up  the  patients  in  about  12  days 
or  so  before  the  operation  of  hysterectomy. 

Operation. — Before  opening  the  abdmen,  commence  with  a 
careful  curettage  of  the  cancer,  followed  by  cauterization.  This 
method  has  been  objected  to  on  the  score  that  it  disseminates 
infectious  germs  or  cancerous  cells.  We  believe  that  this  fear 
is  chimerical  and  we  never  hesitate  to  do  a  preliminary  curettage 
and  cauterization. 

Again  in  destroying  the  ulcerated  cancerous  vegetations, 
habitat  of  an  aerobic  and  anaerobic  bacterial  flora,  we  diminish 
the  risk  of  septic  contamination  during  the  course  of  the  operation 
and  it  often  happens  that  in  so  doing  we  have  discovered  evi- 
dence of  other  propagation  until  then  unknown  and  which  con- 
traindicates  a  more  serious  intervention. 

If  the  curettage  reveals  that  a  hysterectomy  may  follow  on, 
the  rubber  gloves  are  changed  and  a  new  operative  material  is 
produced  for  the  abdominal  intervention.  The  patient  is 
placed  in  the  Trendelenburg  position  and  the  surgeon  makes  a 
long  incision  so  as  to  get  a  good  exposure  of  the  diseased  parts. 
He  inserts  a  large  retractor  in  the  pubic  angle  of  the  wound  and 
some  compresses  against  the  intestines  and  before  commencing  the 
hysterectomy,  he  makes  with  great  care  an  intraabdominal 
examination  in  order  to  find  out  the  operative  conditions  of  the 
case. 

At  this  stage  he  should  examine,  first,  the  vesico-uterine  fold 
and  see  if  it  is  invaded  by  a  cancerous  nodule ;  in  presence  of  such 
nodules,  we  should  take  into  account  the  presence  of  simple 
cicatricial  contraction  of  this  fold.  The  examination  should  now 


362  ABDOMINAL   HYSTERECTOMY 

be  extended  to  the  broad  ligaments  and  extensive  infiltrations 
may  be  found  in  the  aortic  and  presacral  glands.  As  a  result 
of  this  examination  we  decide  whether  a  radical  operation  is 
necessary  or  a  palliative  intervention.  This  latter  may  include 
a  hysterectomy  and  the  excision  of  the  uterus  constitutes  in 
certain  cases  the  best  of  palliatives.  It  is  certain  that  no  exten- 
sive extirpations  should  be  made  in  the  cellular  tissue,  and  in 
order  to  reduce  the  immediate  operative  risks  to  a  minimum, 
the  surgeon  should  confine  himself  to  a  simple  operation  and  not 
carry  out  the  complex  manipulations  of  the  cleaning  out  of  the 
pelvis. 

If  a  radical  operation  is  decided  upon,  do  it  as  follows:  The 
uterus,  having  been  seized  with  care,  is  drawn  upward  and  a 
little  to  one  side.  All  violence  must  be  avoided  in  taking  hold 
of  it  on  account  of  the  friability  of  the  degenerated  muscle  fiber; 
it  is  advisable  in  cancers  of  the  body,  to  employ  forceps  pro- 
vided with  teeth  which  penetrate  as  far  as  the  neoplasm,  and 
after  ligature  and  division  of  the  utero-ovarian  pedicles,  the 
upper  portion  of  the  broad  ligament  is  incised  between  the  middle 
broad  ligament  fold  where  the  tube  lies  and  the  anterior  which 
contains  the  round  ligament.  This  latter  is  tied  at  a  little  distance 
from  the  uterus  and  divided;  then  the  preuterine  peritoneum  is 
incised  below  the  vesico-uterine  fold.  Separate  the  bladder 
from  the  anterior  surface  of  the  cervix,  which  is  generally  easy 
and  may  be  done  by  pressing  back  the  parts  with  a  strip  of 
gauze;  if  there  are  adhesions  cut  through  them  writh  small  nips 
of  a  blunt-pointed  scissors.  When  the  separator  has  proceeded 
far  enough  on  the  vagina,  we  return  to  the  broad  ligaments  in 
order  to  discover  the  ureters  and  to  tie  the  uterine  arteries ;  gener- 
ally the  anterior  and  posterior  folds  of  the  broad  ligament,  if 
there  is  no  marked  infiltration  of  the  parametrium,  are  separated 
with  ease  like  the  pages  of  a  book.  The  ureter,  in  which,  by  the 
way,  it  is  useless  to  insert  beforehand  a  catheter,  follows,  in  its 
displacement  backward  the  postero-internal  fold  of  the 
broad  ligament.  To  expose  the  field  better,  split  the  peritoneum 
externally  toward  the  iliac  fossa,  as  far  as  the  cecum  to  the 
right  and  the  iliac  colon  to  the  left,  passing  anteriorly  to  the 
utero-ovarian  vessels. 

If  there  are  some  enlarged  glands  found  at  this  level,  separate 


INDICATIONS  FOR  ABDOMINAL   HYSTERECTOMY 


363 


them  from  the  outside  and  remove  them  with  the  cellular  tissue 
around  them  in  drawing  them  toward  the  uterus. 

In  separating  the  parts  of  the  lateral  wall  of  the  pelvis,  the 


FIG.  320. — The  uterus  is  drawn  upward  and  to  the  left.  The  red  dotted  line  shows 
the  incision (in  the  broad  ligament.  The  utero-ovarian  vessels  and  round  ligament  are 
tied. 

large  vessels,  the  lymphatic  and  the  ureter  are  clearly  exposed. 
The  ureter  follows,  as  we  have  already  mentioned,  the  postero- 
internal  fold  of  the  broad  ligament,  which  is  held  tense  by  the 
uterus  being  drawn  to  the  opposite  side.  The  uterine  vessels 


364 


ABDOMINAL    HYSTERECTOMY 


which  are  easy  of  access  are  then  tied  external  to  the  point  where 
they  cross  the  ureter,  without,  however,  going  too  far  outside  in 
such  a  way  as  to  preserve  the  vesical  arteries  which  spring 


FIG.  321. — The  broad  ligament  has  been  split.     The  ureter  may  be  seen  following  the 

displaced  postero-internal  fold. 


sometimes  from  the  hypogastric  by  a  common  trunk  with  the 
uterine  artery.  Then  place  a  pair  of  Kocher's  forceps  on  this 
vascular  pedicle  nearly  level  with  the  uterus  in  such  a  manner 
as  to  prevent  all  hemorrhagic  reflux  by  the  veins,  and  then  the 


INDICATIONS  FOR  ABDOMINAL  HYSTERECTOMY 


.365 


uterine  veins  and  arteries  are  divided   immediately  inside  the 
ligature. 

Raising  the  pedicle  of  uterine  vessels  with  the  cellular  tissue 
that  surrounds  them,  it  is  carried  toward  the  median  line  and 


FIG.  322. — Division  of  the  vesico-uterine  peritoneum  which  is  followed  by  separation  and 
the  pressing  of  the  bladder  forward. 

the  ureter  is  freed  with  a  blunt  instrument  as  far  as  the  bladder, 
preserving,  however,  its  con junctival- vascular  sheath  and  as  much 
as  possible  of  its  posterior  connections  so  as  to  best  preserve  its 


366 


ABDOMINAL   HYSTERECTOMY 


nutrition.     In  the  neighborhood  of  the  bladder  it  is  impossible, 
however,  to  isolate  completely  this  canal  (Fig.  323). 

Drawing  the  uterus  strongly  forward  and  upward   we  cut 
through  the  utero-sacral  ligaments,  after  tying  them  behind  and 


FIG.  323. — The  uterine  artery  has  been  tied  and  divided.  With  the  curved  and 
blunt  scissors  the  ureter  is  isolated  and  at  the  same  time  its  own  cellular  sheath  is  pre- 
erved. 

below  the  ureter,  as  near  as  possible  to  the  wall  of  the  excavation. 
As  a  rule  we  insert  several  successive  stitches  and  as  many  liga- 
tures in  order  to  take  up  the  arteries,  veins  and  lymphatics  that  are 
contained  in  these  ligaments. 


INDICATIONS  FOR  ABDOMINAL   HYSTERECTOMY 


.367 


As  soon  as  they  have  been  cut  across  above,  using  stitches 
already  inserted,  the  recto-uterine  peritoneum  is  made  tense  and 
is  divided  and  it  is  separated  by  pressing  back  with  a  gauze 
compress  the  anterior  face  of  the  rectum.  As  one  divides  the 


FIG.  324. — The  uterus  has  been  drawn  upward  and  forward  and  the  peritoneum  pos- 
teriorly and  the  utero-sacral  ligaments  will  next  be  divided  along  the  red  dotted  line. 

utero-sacral  ligaments,  it  is  observed  that  the  uterus  and  vagina 
mount  toward  the  wound,  and  this  facilitates  the  cleavage 
between  the  vagina  and  rectum.  Finally  the  superior  one-third 


368 


ABDOMINAL   HYSTERECTOMY 


or  even  the  one-half  of  the  vagina  is  seen  to  emerge  from  the 
excavation  (Fig.  324). 

Curved  forceps  may  be  placed  on  the  last  named  (Fig.  316), 
following  the  practice  of  Wertheim,  taking  care  that  the  two 


FIG.  325. — The  operation  is  finished,  the  true  pelvis  is  clothed  with  peritoneum,  the 
pre-rectal  peritoneum  is  sutured  in  the  middle  to  the  retro-vesical  peritoneum. 

forceps  cross  so  as  to  close  the  whole  width  of  the  vagina;  this 
is  then  divided  with  a  scalpel  below  the  forceps  in  such  a  manner 
as  to  remove  the  cancer  in  an  isolated  space.  Bumm,  whose 
practice  we  have  often  followed,  does  not  use  curved  forceps, 


INDICATIONS  FOR  ABDOMINAL  HYSTERECTOMY  369 

which  to  a  certain  extent  hamper  the  extensive  removal  of  the 
parts. 

He  opens  the  vagina  as  far  away  as  possible,  commencing 
his  incision  on  the  least  affected  side  of  the  tumor  and  then  finally 
attacking  the  most  affected  tissues.  He  makes  a  sort  of  pedicle 
of  the  cancer  in  order  to  procure  at  its  site  the  maximum  of 
extirpation. 

Pollosson  recommends  that  once  the  uterus  and  vagina  have 
been  removed  with  the  parametrium  and  enlarged  glands  included, 
to  look  for  glands  which  may  exist  in  the  pelvic  wall  about  the 
level  of  the  bifurcation  of  the  iliac  vessels,  extending  along  the 
length  of  the  common  iliac  vessels  and  into  the  obturator  fossa. 
THey  are  recognized  by  sight  and  touch.  Having  located  them, 
their  dissection  should  be  made  with  care,  without  crushing 
them,  and  endeavoring  to  remove  with  them  the  cellular  tissue 
in  which  they  are  surrounded. 

Having  removed  them,  glance  over  the  operative  field,  tying 
bleeding  points  and  suture  the  peritoneum  laterally  as  after  an 
ordinary  hysterectomy,  uniting  the  retro-vesical  to  the  pre-rectal 
peritoneum.  As  a  preliminary  to  this,  insert  some  iodoform 
gauze  into  the  vagina  (Fig.  325). 

To  produce  drainage,  Amann  advises  incising  the  posterior 
wall  of  the  vagina  with  a  thermocautery  as  far  as  the  inferior 
limit  of  the  lateral  separation. 

Modifications  of  the  Operation. 

Preliminary  Freeing  of  the  Vagina.— Some  surgeons1  have  advised  com- 
mencing the  operation  by  a  freeing  of  the  vagina.  After  a  circumferential 
incision  of  the  vulvar  orifice,  they  dissect  up  a  mucous  membranous  cuff 
over  an  extent  of  about  4  cm.,  and  they  then  close  this  cuff  with  a  purse- 
string  suture.  The  rawed  surfaces,  resulting  from  this  separation,  are 
brought  together  by  sutures  and  the  vulva  is  closed  with  the  exception  of 
a  small  space  reserved  for  the  introduction  of  a  drain. 

The  perineal  stage  of  the  operation  being  finished,  the  surgeon  goes  on 
to  the  abdominal  stage  and  removes  the  uterus  "en  bloc"  with  the  vagina 
as  a  closed  cavity. 

We  are  enabled  thus  to  avoid  the  contamination  of  the  wound  with  the 

1  Imbert  and  Fieri.  Bull,  de  la  Soc.  de  Chir.,  1905,  p.  925,  et  Annales  de  gynecologic, 
T.  LXIII,  p.  655;  P.  Duval,  Bull,  de  la  Soc.  de  Chir.,  June,  1906,  Report  by  J.  L.  Faure, 
p.  573. 

24 


370  ABDOMINAL   HYSTERECTOMY 

septic  products  of  cancer  at  the  same  time  to  avoid  the  cancerous  grafts 
during  the  operation.  In  addition,  the  primary  division  of  the  vagina  by 
leaving  the  uterus  free  to  mount  upward,  permits  us,  according  to  J.  L. 
Faure,  to  remove  in  the  abdominal  stage  of  the  operation  both  the  uterus 
and  the  peri -cervical  region  almost  on  a  level  with  the  abdominal  wound, 
which  greatly  facilitates  the  delicate  dissection  of  theureterand  parametrium. 
Transverse  Incision  of  the  Wall  and  Partitioning  of  the  Abdomen. — In  cases 
of  extensive  cancers,  Mackenrodt  and  Amann  advise  making  a  transverse 
incision  in  the  abdominal  wall  and  of  cutting  through  the  recti  and  thus  give 
a  full  exposure  of  the  parts.  Having  opened  the  abdomen  they  separate 
the  peritoneum  from  the  deep  aspect  of  the  anterior  abdominal  wall  and 
suture  it  to  the  posterior  aspect  of  the  pouch  of  Douglas,  thus  shutting  off 
the  large  peritoneal  cavity  and  isolating  by  this  septum  the  operative  field. 

In  order  to  have  a  more  enduring  partition,  Kronig  takes  the  fascia 
transversalis  with  the  peritoneum  and  thus  avoids  necrosis  of  the  flap  and 
the  later  bursting  through  of  the  intestine  into  the  suppurative  operative 
field,  a  state  of  affairs  noted  in  some  cases. 

In  this  procedure  make  a  curved  incision  which  passes  one  finger  breadth 
above  the  pubis  and  extends  to  within  three  finger  breadths  of  the  antero- 
superior  spine  of  the  ilium  on  both  sides;  cut  through  the  skin  and  aponeuro- 
sis  and  then  the  recti  about  one-half  a  finger's  breadth  above  the  pubis.  Tie 
the  epigastric  vessels  which  are  to  be  seen  on  the  external  surface  of  the 
peritoneum. 

Drawing  the  musculo-cutaneous  flap  upward,  we  put  on  tension,  the  peri- 
toneum forming  the  floor  of  the  wound  and  we  can  ascertain  the  limits  of  the 
bladder.  We  must  not  draw  too  strongly  so  as  to  separate  the  bladder  from 
the  symphysis;  if  its  limits  are  not  to  be  seen  plainly,  we  may  recognize  them 
by  palpation.  We  then  open  the  peritoneum  above  the  bladder. 

Lower  the  head  a  little  more  at  this  stage  so  that  the  intestines  fall  to- 
ward the  diaphragm  and  suture  the  peritoneal-transversalis  fascia  flap  to  the 
peritoneum  of  the  posterior  wall  of  the  pelvis,  beginning  by  a  stitch  which 
unites  the  utero-ovarian  pedicles  to  the  flap  and  then  attaching  this  in  front 
of  the  rectum.  Laterally  isolate  the  peritoneal  cavity  by  suturing  the  an- 
terior lip  of  the  broad  ligament,  previously  split,  to  the  peritoneum  of  the 
lateral  wall  of  the  abdomen.  We  thus  gain  a  splendid  view  of  our  field  of 
operation,  and  at  the  same  time  an  occlusion  of  the  peritoneal  cavity  which 
prevents  any  irruption  of  the  intestine.  The  uterus,  upper  part  of  the 
vagina,  and  the  parametrium  are  extirpated  in  the  usual  manner. 

Mackenrodt  recommends  detaching  the  parametrium  from  the  pelvic 
wall  in  order  to  remove  it  in  its  entirety  with  juxta-rectal  and  pre  sacral  glands. 
We  then  see  the  glands  along  the  length  of  the  iliac  and  obturator  vessels 
which  are  removed  secondarily.  Finally  insert  a  vaginal  wick.  The  uterus 


INDICATIONS  FOR  ABDOMINAL   HYSTERECTOMY  371 

must  not  be  in  contact  with  the  gauze;  to  this  end,  bury  it  by  suturing  the 
lateral  portion  of  the  extremity  of  the  vagina  either  to  the  bladder  or  to  the 
vesical  peritoneum.  Close  the  operative  field  above  by  uniting  the  vesical 
peritoneum  to  the  rectal  peritoneum  and  carrying  the  sutures  as  far  laterally 
as  the  utero-ovarian  pedicles. 

On  the  fifth  day  remove  the  gauze  wick  and  make  the  patient  sit  up  in 
order  that  the  intraabdominal  pressure  may  diminish  as  much  as  possible  the 
existing  cavity. 

Complications. — The  most  important  complication  is  either 
infection  of  the  peritoneum,  or  of  the  cellular  tissue,  and  according 
to  Bumm1  in  cases  of  cancer,  infection  extends  much  further 
than  the  tumor,  even  to  the  extent  that  the  tissues  in  the  neigh- 
borhood of  the  uterus  are  almost  constantly  found  to  contain 
streptococci.  In  operating  on  these  infected  tissues,  that  infection 
of  the  peritoneum  and  the  wound  should  take  place  is  not  to  be 
wondered  at.  Patients  who  had  fever  before  their  operation 
are  particularly  dangerous  subjects. 

Curettage  followed  by  thermo-cauterization  is  insufficient  as 
the  thermo-cautery  hardly  extends  its  action  1  cm.  deep. 

In  order  to  have  a  more  complete  disinfection,  Mackenrodt, 
after  a  curettage  carried  out  on  the  day  before  the  operation, 
tampons  the  vagina  and  the  cancerous  cavity  with  a  long  strip 
of  gauze  steeped  in  a  solution  of  10  per  cent,  commercial  formol, 
which  is  then  gently  expressed.  The  vulva,  the  anus  and  in- 
ternal surface  of  the  thighs  are  greased  with  vaseline  so  as  to 
avoid  the  irritating  action  of  any  drops  which  may  overflow,  and 
Bumm  tries  also  antistreptococcal  vaccination  but,  up  to  now, 
has  obtained  no  results. 

Fresh  research  appears  essential  to  us  in  order  to  establish 
the  cause  of  postoperative  infections  which  are  frequent  enough 
after  abdominal  hysterectomy.  We  think,  however,  that  it  is 
useless  to  always  call  into  question  the  preliminary  infection  of 
the  cellular  tissue  of  the  broad  ligaments  and  hold  that  the 
length  of  the  operation  and  the  contusive  manipulations  suffice 
to  explain  certain  cases  of  cellulitis  or  peritonitis. 

The  same  reasons  cause  shock  to  be  dreaded  particularly 
in  fat  patients  with  cardio-pulmonary  affections. 

1  Bumm,  Zur  technik  der  abdominalen  Extirpation  de  Karzinomatosen  Uterus. 
Zeitsch.fur  Geb.  und  Gyn.,  Stuttgart,  1905,  T.  LV,  p.  173. 


372  ABDOMINAL  HYSTERECTOMY 

With  the  exception  of  infection  and  shock,  the  other  most 
frequent  complications  are  those  connected  with  the  urinary 
system. 

Albuminuria  with  nephritis  is  not  exceptional  and  may  lead 
to  a  fatal  termination. 

Cystitis  is  very  frequent  and  ought  to  be  treated  by  catheteri- 
zation  and  washing  out  of  the  bladder.  The  traumatic  lesions  of 
the  bladder  may  be  produced  during  its  separation ;  late  necrosis  is 
rarer.  It  may  be  in  connection  with  a  too  extensive  denudation 
of  the  bladder  and  an  insufficient  re-clothing  of  it. 

According  to  Mackenrodt  the  principal  cause  of  this  late 
necrosis  is  the  participation  of  the  bladder  in  the  peri-cancerous 
inflammatory  process.  He  advises  in  case  of  adhesions  to  freely 
resect  the  bladder,  preserving  the  mucous  membrane  if  possible 
and  doing  an  immediate  suture. 

The  lesions  of  the  ureter1  are  much  more  important:  this 
canal  may  be  wounded  during  the  operation ;  it  has  been  wounded 
thus  eight  times  in  a  primary  series  of  200  cases  by  Wertheim; 
three  times  in  a  second  series  equally  of  200  cases.  Secondary 
necrosis,  followed  by  urinary  fistula,  coming  on  about  the  seven- 
teenth or  eighteenth  day  has  been  observed  in  24  out  of  400  cases 
or  about  6  per  cent,  of  cases. 

It  is  the  consequence  of  too  extensive  denudation  of  the 
ureter  which  floats  like  a  telegraphic  wire  in  the  field  or  perhaps 
the  ureter  fixed  by  the  cancer  in  the  neighborhood  of  the  cervix 
has  been  so  injured  that  its  wall  has  lost  its  resistance. 

In  order  to  avoid  this,  during  the  course  of  the  operation,  we 
should  never  lose  the  ureter  from  sight  nor  pinch  it  up,  nor  draw 
upon  it,  and  finally  not  to  isolate  it  from  its  surrounding  cellular 
tissue.2 

In  traumatic  lesions,  it  is  necessary  to  do  a  uretero-cysto- 

1  Wilhelm  Weibel,  Das  Verhalten  der  Ureteren  nach  der  erweiterten  abdominalen 
Operation  der  Uteruskarzinoms.     Zeitsch.  f.  Geb.  und  Gyn.,  Stuttgart,  1908,T.  LXII,  p. 
184.     Kronig  resected  the  ureter  voluntarily  twelve  times  in  order  to  increase  the  opera- 
bility  of  the  case,  and  once  only  for  fear  of  second  necrosis. 

2  Amann  advises  including  the  terminal  part  of  the  ureter  in  the  thickness  of  the 
vesical  wall  by  inserting  some  sutures  which  take  up  the  most  dependent  portion  of  the 
posterior  aspect  of  the  bladder  and  unite  it  to  the  vesical  peritoneum;  he  maintains  the 
first  portion  applied  to  the  lateral  wall  of  the  pelvis  by  uniting  the  pedicle  of  the  uterine 
artery  to  the  lateral  peritoneum  which  is  drawn  a  little  downward.     The  ureter  is  thus 
maintained,  so  to  speak,  "  on  horseback, "  on  a  fork  formed  by  the  uterine  artery  and  the 
hypogastric  artery  which  lifts  it  up  and  applies  it  to  the  lateral  wall  of  the  pelvis  (Amann, 
Ureterdeckung    und    Drainage    bei    ausgedehnter    Beckenausraumung   wegen    Uterus 
karzinom.     Zeitsch.  fur  Geb.  und  Gyn.,  Stuttgart,  1907,  T.  LXI,  p.  2). 


INDICATIONS  FOR  ABDOMINAL  HYSTERECTOMY  373 

neostomy  immediately ;  on  the  contrary,  however,  in  fistulas 
following  on  necrosis  of  the  canal,  there  is  no  need  to  be  in  hurry 
to  do  an  intervention.  These  fistulas  heal  spontaneously  in  70 
per  cent,  of  cases,  from  twro  weeks  to  four  months  after  the 
operation  and  with  conservation  of  the  permeability  of  the  ureter. 
We  should  not  hasten  to  a  too  early  nephrectomy  until  there  are 
marked  signs  of  ascending  infection;  the  uretero-cysto-neostomy 
should  be  done  in  persistent  fistula,  when  the  corresponding 
kidney  is  healthy  or  even  when  diseased  unless  a  disease  of  the 
opposite  kidney  contraindicates  nephrectomy. 

Results. — Abdominal  hysterectomy  with  resection  of  the 
vagina  and  parametrium  should  be  considered  from  a  triple 
point  of  view:  1.  Operability;  2.  Immediate  results;  3.  Remote 
results. 

1.  Operability. — The  abdominal  operation,  such  as  has  been 
done  for  the  last  ten  years,   has  enabled  us  to  extend  the  do- 
main of  radical  operations. 

Pollosson  managed  to  operate  56  per  cent,  of  cancers  that 
came  to  hospital ;  Wertheim,  60  per  cent,  to  65  per  cent. ;  Doder- 
lein,  69  per  cent. ;  Bumm,  80  per  cent. ;  Kronig,  87  per  cent. 

That  is  to  say,  a  great  number  of  surgeons  do  not  hesitate 
to  have  recourse  to  a  radical  operation  in  those  cases  W7hich  wpuld 
certainly  never  have  been  done  before. 

2.  Immediate  Results. — In  spite  of  the  great  extension  of  the 
operation,  the  mortality  is  hardly  more  elevated  than  it  was  for- 
merly in  the  days  of  vaginal  hysterectomy.     Leaving  on  one  side 
cancers  of  the  body,  the  mortality  from  which  is  almost  nil,  and 
considering   only    the   cancers   of   the   cervix   we   arrive   at   the 
following  results. 

Mackenrodt1  in  69  cases  had  16  deaths =20  per  cent.  In 
reality,  the  mortality  is  much  less,  because  at  the  commence- 
ment Mackenrodt  reserved  the  abdominal  operation  to  cases 
which  were  unable  to  be  extirpated  by  the  vagina.  Since  he 
operated  all  cancers  by  the  abdomen  his  mortality  fell  to  about 
11  per  cent. 

Doderlein,2  47  cases,  7  deaths  =  14.8  per  cent. 

1  Mackenrodt,    Ergebnisse    der    abdominalen    Radikaloperation    der    Gebarmutter- 
scheidenkrebses    mittels    Laparotomia    hypogastrica.     Zeitschr.  fur    Geb.    und    Gun., 
Stuttgart,  T.  LIV,  p.  514. 

2  Doderlein  and  Kronig,  Operative  Gynakologie,  Second  Edition,  Leipzig,  1907. 


374  ABDOMINAL   HYSTERECTOMY 

Bumm,1  82  cases,  17  deaths =22  per  cent. 

Pollosson,2  133  cases,  17  deaths  =  12  per  cent. 

Scheib,3  149  cases,  30  deaths  =  20.1  per  cent. 

Franque,4  51  cases,  8  deaths  =  15. 7  per  cent. 

Schindler,5  117  cases,  16  deaths  =  13.67  per  cent. 

Wertheim,6  first  series  of  200  cases,  49  deaths =24. 5  per  cent. 

Later  series  of  200  cases,  20  deaths  =  10  per  cent. 

As  the  second  series  of  Wertheim's  work  appears  we  see  how 
the  mortality  tends  to  diminish.  It  is  the  same  with  Pollosson's 
cases;  while  the  first  series  gave  a  mortality  of  18.5  per  cent,  the 
third  series  gave  only  8.5  per  cent,  and  the  36  last  patients  ope- 
rated are  all  cured. 

This  amelioration  in  the  immediate  results  is  general.  If 
only  recent  cases  were  cited  we  should,  as  Scheib  says,  find  that 
Wertheim  has  a  mortality  of  only  7.5  per  cent,  and  Doderlein, 
5  per  cent.,  figures  which  agree  with  those  of  Koblank,  who  had 
5.4  per  cent,  of  deaths  according  to  his  latest  report. 

In  fact  there  is  a  diminution  in  the  mortality  in  the  abdom- 
inal operation  identical  with  that  which  occurred  in  the  vaginal 
operation  when  the  mortality  fell  from  20  per  cent,  to  4-8 
per  cent. 

3.  Remote  Results. — For  cancers  of  the  body  of  the  uterus 
remote  results  are  excellent;  in  13  cases  of  cancers  operated  by 
Doderlein,  two  died  of  intercurrent  diseases,  twro  died  of  meta- 
stasis in  existence  before  the  operation,  eight  are  without  any 
recurrence  after  more  than  three  and  one-half  years  have  fled. 
According  to  Scheib  75  per  cent,  of  cancers  of  the  body  of  the 
uterus  are  definitely  cured.7 

For  cancers  of  the  cervix  the  remote  results  are  very  superior 
to  those  formerly  the  case  in  vaginal  hysterectomy ;  above  all  when 
it  is  considered  that  cancers  regarded  as  inoperable  at  the  time 

1  Bumm,  Zur  Technik  der  abdominalen   Exstirpation  der  karzinomatosen    Uterus. 
Zeitschr.fur  Geb.  und  Gyn.,  Stuttgart,  1904,  T.  LV,  p.  173. 

2  Pollosson,  Hysterectomy  with  Hollowing  Out  of  the  Pelvis.     Lyon  chirurg.,  1909, 
T.  I,  p.  333. 

3  Scheib,  Klin,  und  Anat.  Beitr.  z.  operativ.  Behandl.  des  Uteruscarcinom.     Arch- 
fur  Gyn.,  Berlin,  1909,  T.  LXXXVII,  pp.  1-233. 

*  Franque  (Otto  v.),  Zur  Statistik  der  operativen  Behand.  bei  Uteruskarzinoms. 
Mon.  fur  Geb.  und  Gyn.,  Berlin,  1909,  T.  XXX,  p.  29. 

&  Schindler,  Statist,  und  anat.  Ergebnisse  bei  der  Freund- Wertheim tchen  Radikal- 
operation  der  Uteruskarzinom.  Monat.fiir  Geb.  und  Gyn.,  Berlin,  1906,  p.  78. 

6  Wertheim,  Soc.  internal,  de  chir.,  Bruxelles,  1908,  T.  I,  p.  541. 

7  Scheib,  Klinische  und  anatomische,  Beitrage  zur  operativen  Behandlung  des  Uterus- 
karzinoms.    Archivfiir  Gyn.,  Berlin,  1909,  T.  LXXXVII,  pp.  1  and  233. 


.   INDICATIONS  FOR  ABDOMINAL  HYSTERECTOMY  37o 

when  only  the  vaginal  route  was  practised,  are  removed  by  the 
abdomen.  Bumm  in  46  cases  notes  17  recurrences,  6  patients 
were  lost  to  view  and  23,  of  whom  20  had  been  done  over  two 
years  before,  gave  a  result  of  57  per  cent. 

Wertheim  in  151  cases  after  operation  had  four  deaths  from 
intercurrenf  disease,  59  recurrences  and  88  cures  found  after 
five  years'  interval,  giving  59  per  cent,  of  lasting  cure. 

Mackenrodt  in  144  cases  found  74  per  cent,  of  the  patients 
living  after  a  variable  period  of  eighteen  months  to  six  and  one- 
half  years  after  operation. 

Scheib  in  the  clinic  at  Prague  finds  62.5  per  cent,  of  his  cases 
living  after  two  years,  after  three  years  58.8,  after  five  years 
28.5,  and  after  six  years  27.2. 

Pollosson,  in  1909,  found  35  per  cent,  of  cases  operated  before 
June,  1905,  quite  well;  61  per  cent,  were  operated  in  1905  and 
1906 ;  69  per  cent,  were  operated  in  1907. 

It  is  still  difficult  to  come  to  a  definite  conclusion  with  regard 
to  the  radical  cure  of  uterine  cancers,  as  operations  are  not 
always  made  in  identical  conditions.  It  appears  according  to 
results  published  that  certain  gynecologists,  Bumm,  Mackenrodt 
and  Kronig  for  example,  intervene  in  cancers  with  extensive 
invasions  and  that  they  do  a  very  extensive  extirpation,  search- 
ing for  glands  and  carrying  out  their  excavation  as  far  as  the 
Jevator  and  this  explains  the  considerably  higher  early  mortality 
in  their  results.  Others,  and  particularly  French  surgeons,  are 
not  favorably  disposed  to  the  radical  operation  in  cases  of  cancer 
which  have  manifestly  spread  beyond  the  uterus.  These  differ- 
ences in  the  extension  granted  to  the  operability  of  cases  and  in 
the  extent  of  the  incisions  explains  the  differences  found  in  the 
statistics. 

However,  it  is  established  to-day  that  the  abdominal  operation 
is  superior  to  vaginal  hysterectomy  from  the  point  of  view  of 
early  and  remote  results. 

Hysterectomy  for  Prolapse. 

Abdominal  hysterectomy  is  only  exceptionally  practised  in 
cases  of  uterine  prolapse. 

Its   technic   presents   no   peculiarity   with   the   exception   of 


376  ABDOMINAL  HYSTERECTOMY 

fixing  firmly  the  stump  of  the  cervix  or  the  dome  of  the  vagina 
either  to  the  aponeurosis  or  to  the  muscles1  or  to  the  pedicles 
of  the  broad  ligaments  (Ligamentary  Trachelopexy,  Jacobs). 

The  technic  of  abdominal  hysterectomy  in  puerperal  infection 
has  no  peculiarity.  Here  total  hysterectomy  is  absolutely  indi- 
cated. The  minute  protection  of  the  peritoneal  cavity  will  be 
the  principal  care  of  the  operator  on  account  of  the  extreme 
virulence  of  the  uterine  contents.  It  will  be  found  of  advantage 
as  in  hysterectomy  for  epithelioma  of  the  uterine  cavity  to 
close  the  cervix  by  some  sutures  before  commencing  the  ex- 
cision of  the  uterus. 

Abdominal  hysterectomy  for  puerperal  infection  gives  a  high 
mortality,  6  deaths  in  12  cases  (Mouchotte).2 

Hysterectomy  in  Uterine  Ruptures. 

Hysterectomy  is  indicated  in  complete  ruptures  of  the  uterus. 
In  23  non-operated  ruptures  Pinard  observed  20  deaths,  in 
nine  operated  cases,  five  deaths  only;  it  may  also  be  added  that 
in  two  of  these  last  cases  the  operation  was  done  "in  extremis."3 

The  operative  technic  should,  wre  think,  vary  according  to  the 
seat  of  rupture  either  in  front  or  behind  the  vascular  uterine 
pedicle. 

If  the  rupture  is  situated  behind  the  uterine  pedicle,  hysterec- 
tomy is  done  as  usual,  that  is,  the  uterus  is  divided  at  the  level  of 
the  most  inferior  part  of  the  tear. 

If  the  rupture  lies  in  front  of  the  uterine  pedicle,  as  is  generally 
the  case  in  extensive  lesions  of  the  cellular  tissue,  a  rather  irregular 
supravaginal  hysterectomy  is  done,  dividing,  as  in  the  preceding 
case,  the  uterus  at  the  level  of  the  inferior  part  of  the  rupture, 
but  terminating  by  fixing  the  sutured  uterine  pedicle  to  the  deep 
surface  of  the  abdominal  wall,  marsupializing  and  draining  the 
seat  of  contusion  of  the  broad  ligament.  If  there  are  symptoms 

1  A.  Pollosson,  Total  Abdominal  Hysterectomy  with  Colpopexy  in  the  Treatment  of 
Certain  Prolapses.     Bull,  de  la  Soc.  de  chir,  de  Lyon,  April,  1906,  T.  IX,  p.  137. 

2  Mouchotte,  Documents  to  Help  toward  the  Study  of  Hysterectomy  in  Puerperal 
Infection  Postabortion.     Th.  de  Paris,  1902-1903,  p.  412. 

3  Sauvage,  Pathological  Anatomy  and  Treatment  of  Uterine  Ruptures  During  Labor. 
Th.  de  Paris,  G.  Steinheil,  1901—1902,  No.  305.     The  Statistics  of  the  Munich  Clinic 
show  the  superiority  of  intervention.     All  non-operated  cases  died,  while  the  operation 
saved  40  per  cent.     (F.  Weber,  Die  kompletten  Uterusrupturen  der  letzten  50  Jahre  an 
denMiinchner  Frauenklinik,  Beilr.  z.  Geb.  und  Gyn.,  1909,  T.  XV,  p.  53.) 


INDICATIONS  FOR  ABDOMINAL  HYSTERECTOMY  377 

of  infection  or  if  the  tear  extends  to  the  vagina  it  is  of  advantage, 
as  Dragiescu  and  Cristeanu  advise,  to  do  a  total  hysterectomy 
with  vaginal  drainage.1 

1  Dragiescu  and  Cristeanu,  On  the  Treatment  of  Ruptures  of  the  Uterus.     Ann.  de 
Gyn.,  Paris,  Feb.,  1902. 


CHAPTER  IV. 

OPERATIONS  ON  THE  TUBES  AND    OVARIES. 

Summary. — Removal  of  the  adnexa   (healthy,   inflamed,  neoplasmic); 
conservative  operations  on  the  tube  and  ovary. 

1.  Removal  of  the  Adnexa. 

The  technic  of  the  operation  varies  according  as  we  have 
to  deal  with  healthy  adnexa,  diseased  adnexa  either  from  inflam- 
matory or  neoplasmic  lesions. 

I.  Healthy  Adnexa. 

The  removal  of  healthy  adnexa  is  one  of  the  simplest  of 
operations. 

Operation. — A  small  vertical  incision  or  better  still  a  crucial 
incision  of  the  wall  will  suffice. 

The  abdomen  having  been  opened,  the  intestine  pressed 
back,  thanks  to  the  Trendelenburg  position,  and  protected  by 
compresses,  one  proceeds  to  look  for  the  tube  and  ovary.  The 
hand  being  introduced  behind  the  broad  ligament  finds  the 
adnexa  with  ease  and  draws  them  up  to  the  wound.  Then 
divide  the  utero-ovarian  pedicle  at  the  level  of  the  infundibulo- 
pelvic  ligament.  Cut  across  the  tube  right  up  against  the  uterus 
without  a  preliminary  ligature;  having  done  this,  put  a  ligature 
around  the  uterine  artery  at  the  level  of  the  angle  of  the  uterus 
and  cut  it  external  to  the  ligature.  Then  detach  the  adnexa 
from  the  superior  border  of  the  broad  ligament  without  the 
least  bleeding. 

The  important  point  is  to  remove  the  ovary  in  toto,  cutting 
through  the  ligament  at  some  distance  in  such  a  manner  as  to 
avoid  a  frequently  committed  fault  W7hich  is  to  leave  a  sort  of 
tail  on  the  organ  at  this  level. 

Hemostasis  is  very  easily  realized  by  isolated  ligature  of  the 
vessels;  nothing  remains  but  to  unite  the  two  lips  of  the  broad 

378 


REMOVAL  OF  THE  ADXEXA 


379 


ligament,  burying  the  ligatures  of  the  arterial  pedicles  and  the 
uterine  insertion  of  the  tube. 

This  method  of  removal  is  as  rapid  as  the  too  lengthy  classical 
procedure  which  consists  in  taking  up  with  two  large  inter- 
locked ligatures  all  the  upper  part  of  the  broad  ligament.  It  has 


FIG.  326. — Unilateral  removal  of  the  adnexa.  Two  ligatures  are  applied,  one  close 
against  the  uterus  on  the  termination  of  the  uterine  artery,  the  other  external  to  the 
utero-ovarian  vessels. 


the  advantage  of  filling  the  three  desiderata  that  we  have  already 
on  several  occasions  formulated,  doing  away  with  large  pedicles, 
isolated  ligature  of  vessels,  and  reconstitution  of  the  pelvic 
peritoneum. 

Indications. — The    removal    of    healthy    adnexa    has    been 
advised  in  a  certain  number  of  cases.     On  the  advice  of  Bailey, 


380 


OPERATIONS   ON   THE   TUBES   AND   OVARIES 


it  was  done  formerly  for  nervous  troubles  (hysteria,  insanity, 
epilepsy,  mania,  melancholy,  nymphomania,  etc.).  It  gave  no 
satisfactory  result.  The  only  case  where  it  was  authorized  to  be 
done,  and  still  is,  is  that  condition  where  nervous  troubles  are 
in  relation  to  menstruation  and  where  after  failure  of  medicinal 
therapeutics,  they  are  sufficient  to  make  life  miserable. 


FIG.  327. — Unilateral  removal  of  the  adnexa.     A  catgut  continuous  suture  unites  the 
layers  of  the  broad  ligament,  burying  the  vascular  ligatures. 

Hegar  proposed  it  as  a  palliative  treatment  of  uterine  fibroids. 
To-day  with  a  simplified  technic  of  hysterectomy,  it  has  been 
abandoned  for  operations  which  attack  the  fibroids  directly. 

Oophorectomy  is  still  practised  in  dysmenorrhea  called 
ovarian  and  attributed  to  a  difficult  ovulation.  The  exami- 
nation of  ovaries  removed  reveals  no  lesion ;  it  appears  that  one 
is  confronted  by  a  simple  neurosis  and  which  hardly  ever  calls 
for  operation. 


REMOVAL  OF  THE  ADNEXA  381 

Prolapse  of  ovaries,  which  frequently  accompanies  radiating 
pains,  and  pains  in  coitus  and  defecation,  etc.,  has  been  regarded 
as  an  indication  for  oophorectomy ;  to-day  we  prefer  ovariopexy. 

Fehling  advised  the  removal  of  the  ovaries  in  osteomalacia, 
Beatson  in  inoperable  cancer  of  the  breast.  It  is  certain  that 
amelioration  was  obtained  in  osteomalacia,  but  in  inoperable 
tumors  of  the  breast  the  results  announced  had  been  contested. 

Finally,  some  accoucheurs  have  practised  it  when  a  narrowing 
of  the  pelvis  necessitated  a  Cesarean  section  in  order  to  prevent 
another  pregnancy.  It  is  more  logical  to  remove  only  the  tubes 
or  to  simply  remove  a  segment  between  the  two  ligatures.  The 
patient  cannot  conceive  again  while  she  preserves  the  internal 
secretion  of  the  ovary  and  a  normal  menstruation. 

II.  Inflammations  of  the  Adnexa. 

Operation. — When  the  adnexa  show  inflammatory  lesions  the 
course  of  the  operation  proceeds  as  in  that  for  healthy  adnexa. 
But  in  the  former  we  have  superadded  a  special  condition, 
which  comprises  the  most  delicate  part  of  the  operation — the 
freeing  of  the  adhesions.  In  studying  abdominal  hysterectomy 
we  have  insisted  on  the  different  characters  of  the  adhesions 
and  on  the  manner  of  detaching  them  and  the  treatment  of  the 
complications  following  on  their  liberation.  We  will  not  return 
to  this  subject. 

Indications. — The  bilateral  removal  of  the  adnexa  has  been 
considered  for  some  time  as  the  treatment  of  choice  in  inflam- 
mation of  the  adnexa.  To-day  it  is  the  rule  to  always  do  a 
hysterectomy  at  the  same  time.  To  preserve  the  uterus  when 
the  adnexa  from  both  sides  have  been  removed  is,  to  us,  ridiculous. 

If  one  wishes  to  do  a  conservative  operation  it  is  above 
all  the  ovary  that  one  should  keep.  The  uterus,  after  removal 
of  the  adnexa,  has  no  purpose.  Generally  inflamed,  it  con- 
stitutes a  useless  heavy  organ,  which  is  the  origin  of  pain  and 
various  discharges.  Its  removal,  far  from  complicating  the 
operation,  simplifies  the  operative  procedures  by  doing  away 
with  the  cul-de-sac  of  the  pelvis,  in  making  its  cavity  smooth 
and  in  assuming  a  better  drainage,  where  this  is  wanted. 


382  OPERATIONS   ON   THE   TUBES   AND   OVARIES 

The  limited  removal  of  the  aclnexa  has  only  one  indication, 
that  of  irreparable  lesions  on  one  side  and  a  possible  conserva- 
tism of  the  uterus  and  adnexa  on  the  other  side. 


III.  Neoplasms  of  the  Adnexa. 

The  neoplasms  of  the  adnexa  are  so  various  that  it  is  impossi- 
ble to  describe  an  operative  technic  for  their  removal  which  even 
in  its  broadest  lines  would  be  applicable  to  all  cases. 

Operation. — From  the  point  of  view  of  operation,  neoplasms 
may  be  divided  into  two  groups:  1.  Small,  solid,  or  fluid  neo- 
plasms; 2.  large,  cysts  (ovarian  or  parovarian). 

1.  Extirpation    of   small   neoplasms    (papillomas,    sarcomas, 
carcinomas  of  the  tubes,  solid  tumors  of  the  ovary,  etc.)  resembles 
greatly  the  operation  employed  for  removal  of  healthy  or  inflamed 
adnexa.     The   abdominal   incision   should    be   long   enough   to 
permit  of  an  easy  execution  of  intraabdominal  manipulations. 

Soft  tumors  and  papillomas  bleed  when  they  are  drawn 
externally.  It  is  useless  to  arrest  the  hemorrhage  in  their  friable 
tissues  and  it  is  necessary  to  search  for  their  vascular  trunks  as 
rapidly  as  possible  along  the  length  of  the  pelvis  and  near  the 
uterus  and  then  to  clamp  and  tie  them.  When  the  hemorrhage 
is  menacing  we  are  forced  to  remove  as  soon  as  possible  the  mass 
of  the  tumor.  Stop  the  hemorrhage  and  immediately  do  a 
minute  toilet  of  the  pelvis  in  order  to  find  and  remove,  if 
necessary,  the  abdominal  pieces  of  the  neoplasm. 

As  in  inflammatory  lesions  the  concomitant  removal  of  the 
uterus  is  necessary  in  bilateral  lesions. 

2.  The   removal   of   large   cystic  tumors  presents   a   certain 
number  of  peculiarities. 

In  the  usual  form  of  the  ovarian  cyst,  the  question  of 
preliminary  puncture  presents  itself.  It  is  not  so  much  a 
question  of  puncture  as  means  of  diagnosis,  and  justly  an  explor- 
atory celiotomy  is  to  be  preferred  as  being  less  blind  and  less 
dangerous.  It  is  no  longer  a  question  of  puncture  as  a  thera- 
peutic agent;  it  is  only  done  in  patients  whose  condition  is  al- 
most despaired  of  or  where  too  advanced  age  contraindicates  any 
serious  intervention.  We  allude  to  the  enormous  ovarian  cysts, 
with  respiratory  trouble,  edematous  infiltration  of  the  wrall,  cases 


REMOVAL  OF   THE  ADNEXA  383 

in  which  the  abdominal  tension  is  such  that  when  the  tumor  is 
removed,  more  or  less  grave  troubles  are  apt  to  supervene. 

In  these  cases,  preliminary  puncture  may  render  service.  If 
carried  out  two  or  three  days  before  the  operation,  it  presents  no 
inconvenience  and  prepares  the  patient  to  withstand  the  removal 
of  the  enormous  mass  which  she  is  accustomed  to. 

The  operation  is  conducted  in  the  following  manner:  The 
table  on  wrhich  the  patient  lies  is  almost  horizontal  and  the 
first  stages  of  the  operation  are  done  in  this  position.  Whatever 
be  the  volume  of  the  cyst,  commence  by  making  an  incision  of 
medium  length,  and  the  evacuation  of  the  intracystic  fluid 
permits  most  often  of  reducing  the  tumor  by  a  large  proportion. 
The  peritoneum  should  be  opened  writh  caution  in  order  to 
avoid  the  wounding  of  the  venous  sinuses  which  twist  about  in 
the  substance  of  the  cystic  \vall  and,  above  all,  do  not  prema- 
turely open  the  pocket.  This  opening  would  have  as  a  con- 
sequence the  effusion  of  the  cystic  contents  into  the  abdominal 
cavity ;  and  although  the  contents  are  generally  aseptic,  its  effusion 
into  the  peritoneum  w7ould  help  the  conflagration  of  infectious 
complications ;  moreover,  it  helps  to  graft  epithelial  elements  and 
the  development  of  secondary  tumors.1  It  should  thus  be 
avoided. 


FIG.   328. — Trocar  for  ovarian  cysts. 


The  abdomen  having  been  opened,  the  operative  field  is 
limited  with  aseptic  compresses,  which  are  insinuated  between 
the  cyst  and  the  wall  and  which  completely  tampon  ,the  peri- 
toneal cavity  and  cover  over  the  lips  of  the  abdominal  incision. 
Puncture  the  cystic  mass  at  a  point  wThere  there  are  no  large 
vessels  and  with  a  stout  trocar,  to  which  is  attached  a  rubber 
tube  and  an  aspirator,  or  else  the  extremity  of  the  tube  rests  in  a 

1  Hartmann  and  Lecene,  Neoplasmic  Grafts.     Ann.  de  Gyn.,  Paris,  1907,  p.  65. 


384  OPERATIONS  ON  THE  TUBES  AND   OVARIES 

vessel  alongside  the  operator.  As  soon  as  the  cyst  commences 
to  empty,  the  assistant  increases  the  pressure  slowly  on  the  abdom- 
inal wall  with  his  hands. 

Continue  until  the  wall  follows  the  retreat  of  the  cystic  pouch. 
When  this  latter  becomes  folded,  the  operator  seizes  it  with 
forceps  so  as  to  draw  it  gently  externally.  Do  not  draw  roughly 
on  the  forceps  as  the  cystic  wall  often  is  very  friable.  If  the 
cyst  is  unilocular,  as  is  the  case  in  parovarian  cysts,  the  sac 
empties  itself  completely  and  may  with  great  facility  be  drawn 
outside  through  a  very  little  incision  in  the  wall.  If  there  are 
several  loculi,  empty  the  largest  by  perforating  them  with  the 
trocar  point  which  is  left  in  the  primary  puncture  point,  and 
consecutively  perforates  the  walls  of  the  various  loculi. 

Once  the  volume  of  the  cyst  is  sufficiently  reduced,  draw 
out  the  trocar  and  obliterate  the  orifice  of  the  fracture  with  the 
aid  of  a  special  forceps  called  cyst  forceps  and  draw  the  cyst 
with  the  semi-solid  portion  it  contains  out  of  the  abdomen. 
At  this  stage  elevate  the  pelvis,  isolating  the  intestine  carefully 
with  compresses  and  then  we  treat  the  pedicle. 


FIG.  329.— Cyst  forceps. 

The  length  and  thickness  of  the  pedicle  vary  greatly. 
Formed  by  the  superior  part  of  the  stretched  broad  ligament,  it 
contains  the  uterine  and  utero-ovarian  vessels  which  are  apt  to 
be  mingled  in  a  single  group  as  in  the  removal  of  healthy  or 
inflamed  adnexa,  one  is  forced  to  tie  the  internal  vascular  pedicle 
and  the  external  vascular  pedicle  separately  without  interlocking 
the  two  ligatures.  The  central  part  intermediate  between  the 
two  ligatures  does  not  generally  bleed,  and  if  a  vessel  has  escaped 
the  two  principal  ligatures,  nothing  is  simpler  than  to  enclose 
it  in  an  extra  ligature ;  conclude  by  uniting  with  a  continuous 


REMOVAL  OF  THE  ADNEXA  385 

suture  the  two  folds  of  the  broad  ligament  at  the  level  of  the 
space  intermediate  between  the  two  vascular  pedicles,  which 
one  is  careful  to  bury  under  the  line  of  sutures. 

Operative  Complications. — The  operation  presents  sometimes 
a  certain  number  of  difficulties. 

Adhesions. — Extensive  parietal  adhesions  may  lead  to  two 
complications  when  the  incision  is  made  in  the  wall,  depending 
upon  where  the  peritoneal  is  incised;  one  may  go  too  far  and 
incise  the  cyst  without  knowing  it  or  on  the  contrary  taking  the 
modified  peritoneum  for  the  external  wall  of  the  cyst  one  sepa- 
rates it  from  the  other  layers  of  the  wTall,  in  the  idea  that  peri- 
cystic  adhesions  are  being  liberated. 

~  There  is  a  very  simple  means  of  avoiding  these  two  operative 
faults;  it  is,  when  in  doubt  to  increase  upward  the  abdominal 
incision;  in  prolonging  it  sufficiently,  we  arrive  eventually  at  a 
point  where  the  peritoneum  is  free.  It  is  easy  then  to  find  one's 
whereabouts  and  to  continue  the  operation. 

There  is  an  advantage  in  liberating  the  parietal  adhesions 
before  puncturing  the  cyst. 

The  stretched  tumor  gives  to  the  operator's  hand  a  resistant 
base  on  which  it  glides,  insinuating  itself  between  the  tumor  and 
the  wall,  thus  facilitating  the  detaching  of  the  adhesions. 

The  visceral  adhesions  are  treated  as  usual ;  we  will  not  return 
to  this  point. 

Included  Cysts. — Inclusive  cysts  may  be  in  the  ovary  or 
parovarium.  In  the  former  inclusion  is  incomplete;  it  is,  on  the 
contrary,  always  complete  in  certain  intraligamentous  cysts 
whose  origin  is  still  discussed.  The  course  to  follow  is  the  same 
in  both  cases. 

In  presence  of  an  included  ovarian  cyst,  commence  by 
looking  for  the  two  vascular  pedicles  which  are  no  longer  united 
in  a  single  cord,  as  in  the  usual  case,  where  the  cyst  by  its 
development,  has  stretched  into  a  pedicle  the  superior  portion 
of  the  broad  ligament.  These  vascular  pedicles  do  not  always 
appear  immediately  above  all  the  internal  pedicle,  whose  dis- 
associated elements  twist  over  the  external  surface  of  the  cyst; 
in  these  cases,  one  is  obliged  to  successively  tie  the  isolated 
vessels.  The  ligatures  having  been  inserted,  the  two  pedicles 


25 


386 

are  divided  internal  and  external  to  the  cystic  mass;  they  are 
united  by  a  circular  incision  which  circumscribes  a  large  perit- 
oneal collarette  around  the  portion  of  the  included  cyst.  Apply 
forcipressure  forceps  to  this  collarette  as  landmarks  and  then 
commence  the  separation  of  the  cyst.  We  must  take  care  in  this 
freeing  of  the  intraligamentous  portion  of  the  cyst  not  to  lose  it  so 
as  to  avoid  wounding  of  the  ureter,  uterine  vessels  or  even  the 
large  intestine.1 

In  the  cystic  productions  of  the  broad  ligament  the  enuclea- 
tion  of  one  or  many  loculi  is  done  with  the  same  principles; 
follow  the  cyst  wall  without  being  separated  from  it  more  than  a 
millimeter  and  that  without  preliminary  ligature  of  the  vascular 
pedicles.  It  happens  often  that  one  removes  in  toto  the  cystic 
pouch  without  having  to  use  a  single  ligature. 

When  the  cyst  is  removed,  which  is  no  other  than  the  broad 
ligament  unfolded,  secure  the  bleeding  points  with  care  in  this 
cavity,  which  is  then  isolated  from  the  general  peritoneal  cavity 
by  suturing  the  two  serous  layers  together.  If  oozing  still  per- 
sists in  this  cavity,  marsupialize  it  to  the  wall  and  drain  it. 

Accompanying  Hysterectomy. — In  the  case  of  bilateral  cysts, 
it  is  indicated  to  remove  the  uterus  with  the  adnexa;  we  may 
include  hysterectomy  also  in  the  course  of  the  extirpation  of  an 
included  cyst.  In  cases  of  bilateral  included  cysts,  Olshausen 
and  Fritsch  advise  the  systematic  preliminary  removal  of  the 
uterus;  the  extirpation  is  thus  simplified. 

2.  Conservative  Operations. 

In  the  presence  of  inflammatory  lesions  of  the  adnexa,  we 
may  do  a  certain  number  of  conservative  operations2  which  may 
be  carried  out  on  the  tubes  or  ovaries. 

Conservative  Operations  on  the  Tubes. — The  simplest  of  these 
interventions  consists  in  the  freeing  of  adhesions.  If  one  finds  a 
tube  whose  size  and  consistence  are  not  at  all  changed,  and 
whose  infundibulum  still  remains  permeable,  but  which  has 

1  See  Treatment  of  Tumors. 

2  Montana,  Contribution  to  the  Study  of  Remote  Results  of  Conservative  Operations 
on  the  Adnexa.     Th.  de  Paris,  1898-1899,  No.  620.     F.  N.  Boyd,  Conservative  Surgery 
of  the  Tubes  and  Ovaries,  Journal  of  Obst.  and  Gyn.  of  the  British  Empire,  London, 
1903,  T.  Ill,  p.  241  (Bib.). 


CONSERVATIVE  OPERATIONS 


387 


prolapsed  into  the  pouch  of  Douglas  and  is  more  or  less  adherent 
to  the  pelvic  peritoneum,  it  is  sufficient  to  break  down  the 
adhesions  and  return  the  organ  into  its  normal  situation.  The 


FIG.  330. — Lateral  salpingostomy.     Trace  of  incision  on  the  tube. 


tube  will  require  to  be  fixed  with  one  or  two  sutures  in  its 
new  position  and  is  attached  to  a  fixed  portion  of  the  peritoneum, 
as  for  example  the  infundibulo-pelvic  ligament.  In  other  words, 


FIG.  331. — The  flap  is  turned  back,  serous  surface  fixed  to  serous  surface. 

the  freeing  of  the  tube  is  followed  by  a  salpingopexy.  After 
partial  resection  of  the  ovary,  the  fimbrise  ovaricae  have  some- 
times been  fixed  to  the  pedicle  of  the  ovary,  in  order  to  prevent 


FIG.  332. — Terminal  salpingostomy.     Trace  of  the  excision. 

separation  of  the  two  organs  by  formation  of  later  adhesions 
(Fig.  334,  Pozzi). 

Polk  has  endeavored  to  preserve  tubes  with  catarrhal  lesions 
of  the  mucous  membrane  by  expression.     After  having  isolated 


388 


OPERATIONS   ON   THE   TUBES   AND    OVARIES 


the  diseased  tube  with  care  by  sterilized  compresses,  it  is  gently 
expressed  from  its  insertion  outward  so  that  its  contents  are 
expelled.  The  mucous  membrane  may  then  be  cleansed  with 
an  appropriate  solution  which  is  injected  into  the  pavilion  with 
a  syringe. 


FIG.  333. — The  tubal  mucous  membrane  is  sutured  to  the  peritoneum. 

A  conservative  operation  more  frequently  practised  is  salpin- 
gostomy,, a  plastic  operation  having  for  its  aim  the  remedying 
of  the  occlusion  at  the  peritoneal  orifice  of  the  tube.  Carried 
out  for  the  first  time  by  Skutsch,  this  salpingostomy  may  be 
lateral  or  terminal.1 


FIG.  334. — Fixation  of  the  tubular  fimbriae  to  the  ovary  after  partial  excision  of  it. 

In  order  to  do  a  lateral  salpingostomy  (Skutsch),  one  does 
an  oval  excision  of  the  tubal  sac  and  sutures  the  tubal  mucous 
membrane  to  the  peritoneum.  One  can  then,  as  we  have 
already  done,  press  back  a  flap  of  the  tube  and  its  serous 
surface  is  fixed  to  the  serous  surface  of  the  tube  (Figs.  330  and 
331).  In  terminal  salpingostomy  (Martin)  the  obliterated 

1  Skutsch,  Ver  d.  deutsch.  Ges.  f.  Geb.  und  Gyn.,  1889,  T.  Ill,  p.  376.  Jarsaillon,  De 
la  salpingostomie  et  autres  operations  conservatrices  des  trompes  ut^rines.  7  h. 
de  Lyon,  1899-1900,  No.  19.  Kahn,  Some  conservative  operations  de  la  trompe.  Th. 
de  Paris,  1901. 


CONSERVATIVE  OPERATIONS 


389 


extremity  of  the  infundibulum  is  shaved  off  and  then  the  tubal 
mucous  membrane  is  sutured  to  the  peritoneum  (Figs.  332  and 
333).  Clado1  after  having  reformed  a  tubal  infundibulum 
fixed  it  to  the  ovary  (salpingo-ovaro-syndesis) . 

These  conservative  operations  are  only  applicable  to  those 
cases  where  "the  contents  of  the  tube  are  aseptic.  Are  they  really 
useful  ?  The  pregnancies  as  ascertained  by  Gersung,  Delbet, 
Martin,  etc.,  prove  that  at  least  in  a  certain  number  of  cases 
conception  may  follow. 

In  order  to  conclude  the  plastic  operation  on  the  tubes,  we 
will  mention  a  salpingoplasty  made  by  Vidal,  who  performed 
on  the  stenosed  tube  an  operation  in  all  points  comparable  to 
pyloroplasty.2 

Conservative  Operations  on  the  Ovary. — Contrary  to  opera- 
tions on  the  tubes,  conservative  operations  on  the  ovaries  have 
been  frequently  done  in  France  following  on  Pozzi's  results  since 
1893.3  These  operations  are  indicated  when  the  tube  is  healthy 


FIG.  335. — Line  of  the  incision  for  partial  resection  of  a  cystic  ovary. 

and  when  a  portion  of  the  ovary  rests  intact  (dermoid  cysts, 
isolated  cysts,  microcystic  degeneration  leaving  the  region  of 
the  hilum  untouched). 

One  may  do  a  resection  or  ignipuncture  of  inflammatory  cysts 
with  the  point  of  the  thermocautery. 

If  a  partial  resection  of  the  ovary  is  desired,  it  is  seized  at  its 
base  between  thumb  and  index-finger,  which  assures  its  fixation 
and  a  temporary  hemostasis.  Two  incisions  which  join  and  go 

1  Clado,    Semaine   Gynecologique,    Paris,    24   Jan.,    1894.     Ayroles,    Salpingo-ovaro- 
Syndesis.     Th.  de  Paris,  1898-1899,  No.  256. 

2  Vidal,  Rev.  de  gyn.  et  de  chir.  abdomen,  Paris,  1900,  T.  IV,  p.  81. 

3  Consult  in  particular  the  work  of  Pozzi,  Resection  and  Ignipuncture  of  the  Ovary. 
Rev.  de.  gyn.  etae  chir.  abdomen,  Paris,  1897,  p.  1. 


390 


OPERATIONS   ON   THE   TUBES   AND   OVARIES 


as  far  as  healthy  tissue  circumscribe  the  diseased  portion  and 
permit  of  its  excision.  This  done,  the  wound  is  sutured  with 
fine  catguts,  which  take  up  the  ovarian  tissue  and  bring  into 
apposition  the  whole  length  of  the  wound  (Figs.  335  and  336). 


FIG.  336. — Continuous  catgut  suture  closing  the  wound  following  on  partial  excision  of  the 

ovary. 

This  partial  resection  of  the  ovary  has  been  combined  with 
extirpation  of  the  tube  by  Polk,  Lejars,  Jayle.1 

The  results  are  far  from  being  constant  from  the  point  of 
view  of  disappearance  of  the  pains,  but  the  functions  are  preserved. 


FIG.  337. — Folding  up  of  the  utero-ovarian  ligament  in  a  case  of  prolapsed  ovary. 

Martin  who  has  done  a  great  number  of  the  operations  notes  19 
per  cent,  who  became  pregnant  after  the  operations. 

Ovariopexy  has  been  done  in  cases  of  healthy  ovaries  which 
have   prolapsed  into  the  recto-uterine   cul-de-sac  and   become 

^lagny,   Salpingectomy  with  Partial   Ovariectomy.    Th.  de  Paris,   1899.     Jayle, 
Presse  m&dicale,  Dec.  30,  1899. 


CONSERVATIVE  OPERATIONS  391 

painful.  Imlach  merely  did  a  shortening  of  the  infundibulo- 
pelvic  ligament;  Bonney,1  did  a  zigzag  fold  of  the  utero-ovarian 
ligament  (Fig.  337) ;  Mauclaire2  and  Barrows3  transposed  the 
ovary  in  front  of  the  broad  ligament,  making  it  pass  from  behind 
forward  through  a  split  in  the  broad  ligament,  which  once  in 
position  in  front  is  shortened. 


FIG.    338. — Barrows'  operation.     Transposition  of  the  ovary  in  front  of  the  broad  liga- 
ment.    Shortening  of  the  round  and  the  infundibulo-pelvic  ligaments. 

Among  conservative  operations  we  should  mention  "ovarian 
grafts,"  which  in  the  last  fifteen  years,  after  publications  of 
Morris  in  1895  and  Knauer  in  1896,  have  been  the  object  of 
numerous  works.4 

It  is  to-day  quite  established  that  an  ovarian  graft  may  take 
place  without  complicating  procedures,  notably  without  vascular 
anastomosis,  but  that  if  the  autograft  succeeds  in  more  than  50 
per  cent,  of  cases,  the  heterograft  succeeds  only  exception- 
ally. These  grafts  are  made  in  the  peritoneum  or  in  the  subcuta- 
neous tissue.  There  is  less  pain  associated  with  the  ovary  if 
placed  in  the  peritoneum  than  if  left  in  the  subcutaneous  tissue. 

As  indications  of  the  ovarian  graft  may  be  mentioned  the 
complications  of  an  early  menopause,  general  and  genital  infan- 
tilism. These  indications  are  a  little  theoretical;  it  is  not  yet 
certain  that  these  grafts  persist  without  modifications,  as  the 

1  Bonney,  The  Treatment  of  Ovarian  Prolapse  by  Shortening  the  Round  Ligament. 
Trans,  of  Obst.  Soc.,  London,  1906.     T.  XL VIII,  p.  339. 

2  Mauclaire,  Sem.  Gyn.,  Paris,  1903,  p.  273,  1905,  p.  41. 

3  Barrows,  Med.  Rec.,  N.  Y.,  1904,  LVI,  p.  601.     At  the  same  time  as  he  transposes 
the  ovary  in  front  of  the  broad  ligament,  Barrows  shortens  the  round  and  infundibulo- 
pelvic  ligaments. 

4  Sauv6,  Ovarian  Grafts  from  the  Surgical  Point  of  View.     Th.  de  Paris,  Steinheil, 
1909;  Ann.  de  gyn.,  Paris,  1910,  p.  155. 


392  OPERATIONS   ON   THE   TUBES   AND   OVARIES 

persistence  of  a  tumefaction  is  not  the  certain  index  of  a  per- 
sistence of  the  graft,  as  all  the  secreting  tissue  may  disappear 
from  the  organ  and  be  replaced  by  fibrous  material;  the  fact 
that  pregnancy  may  occur  in  a  woman  after  a  graft,  where 
both  ovaries  have  been  removed  proves  nothing,  as  the  removal 
may  have  been  incomplete  and  a  third  ovary  exists  in  4  per 
cent,  of  women. 

If  it  is  considered  that  in  a  certain  number  of  cases  an  ovarian 
graft  has  been  removed  on  account  of  pain  then  in  spite  of  its 
simplicity  the  ovarian  graft  as  operation  should  be  abandoned. 


CHAPTER  V. 

ABDOMINAL  OPERATIONS  FOR  DISPLACEMENTS  AND 
DEVIATIONS  OF  THE  UTERUS. 

Summary. — Anterior  abdominal  hysteropexy. — Indirect  hysteropexy. — 
Intra-abdominal  shortening  of  the  round  ligaments. — Cuneo-hysterectomy. 
— Intra-abdominal  shortening  of  the  utero-sacral  ligaments. 

Numerous  abdominal  operations  have  been  carried  out  for 
displacements  and  deviations  of  the  uterus  and  they  may  be 
classed  in  two  large  groups. 

1.  Operations  carried  out  directly  on  the  uterus. 

2.  Operations  on  the  ligaments.     Finally  the  uterus  may  be 
redressed  by  partial  excisions  of  the  uterine  muscle. 

1.  Anterior  Abdominal  Hysteropexy. 

Anterior  abdominal  hysteropexy  is  described  under  the  names 
of  hysterorraphy,  ventral  fixation,  suspension  of  the  uterus,  and 
consists  in  the  formation,  between  the  uterus  and  the  abdominal 
wall,  of  adhesions  constituting  a  sort  of  suspensory  ligament  for 
the  uterus. 

At  first  extraperitoneal  fixation  was  done  by  pushing  up  the 
uterus  with  two  fingers  in  the  vagina  against  the  deep  surface  of 
the  anterior  abdominal  wall  and  then  taking  it  up  \vith  a  large 
curved  needle,  passing  through  the  whole  thickness  of  the  non- 
excised  wall. 

This  led  to  numerous  complications  and  fell  into  disuse 
and  was  succeeded  by  an  intra-abdominal  operation  which  per- 
mits of  the  exploration  of  the  pelvis,  the  breaking  down  of  ad- 
hesions and  the  passage  of  sutures  through  any  given  part  of  the 
uterus. 

Operation. — The  patient  being  in  the  Trendelenburg  position 
an  incision  4  or  5  cm.  long  is  made,  stopping  at  about  2  cm. 
from  the  pubis;  we  may  also  use  a  transverse  incision  of  the 
abdominal  wall. 

393 


394 


ABDOMINAL   OPERATIONS   FOR   DISPLACEMENTS 


Nothing  more  remains  except  to  fix  the  uterus  to  the  wall. 
The  most  various  procedures  have  been  devised,  from  the  point 
of  view  of  the  segment  of  the  uterus  to  fix,  and  the  number  of 
layers  of  the  wall  through  which  the  suspensory  suture  should 
pass. 

From  the  anterior  surface  of  the  portion  immediately  above 
the  isthmus  to  the  upper  portion  of  the  posterior  face,  every  inter- 


FIG.  339. — Abdominal  hysteropexy. 

mediate  portion  has  been  fixed.  The  two  extremes  already 
mentioned  are  chosen  by  Pierre,  Delbet  and  Kelly  respectively. 
One  of  the  most  frequently  employed  procedures  is  that  of 
Terrier. 

It  consists  in  the  passage  of  several  stitches,  passed  through 
the  anterior  wall  of  the  uterus,  the  highest  up  being  placed  below 
the  insertion  of  the  tubes,  the  three  or  four  sutures  being  distant 
about  1  cm.  apart. 

All  the  sutures  are  successively  placed,  their  ends  being  held 
with  forceps  before  being  tied;  they  traverse  the  entire  thickness 


ANTERIOR  ABDOMINAL   HYSTEROPEXY  395 

of  the  abdominal  wall  with  the  exception  of  the  skin  and  fatty 
subcutaneous  tissue.  Before  tying  them  one  must  be  quite 
certain  that  no  loop  of  intestine  or  piece  of  epiploon  lies  between 
the  uterus  and  the  abdominal  wall  (Fig.  339). 

In  order  to  get  a  firmer  attachment  of  the  uterine  wall  to 
that  of  the  abdomen  Leopold  has  advised  the  scraping  of  the 
uterine  surface ;  Thiriar  advises  the  denudation  of  its  surface  with 
the  same  object;  absorbable  or  partly  absorbable  sutures  are  to 
be  used  and  the  whole  or  most  of  the  abdominal  wall  has  been 
taken  up  in  their  loop. 

On  the  contrary,  other  operators  only  take  up  a  limited 
portion  of  the  uterus  and  the  cellular  tissue  immediately  sub- 
jacent. This  is  Kelly's  practice,  who  says  that  he  gets  adhesions 
which  gradually  stretch  and  finally  form  more  or  less  long 
frenums  which  maintain  the  uterus  in  light  anteversion,  but  at 
the  same  time  allow  it  a  certain  mobility. 

The  method  of  disposition  of  the  sutures  varies  infinitely;  the  majority 
of  operators  place  them  transversely,  while  others  make  non-penetrating 
sutures  for  a  short  distance  in  the  uterine  tissue  (Terrier),  while  others  only 
make  up  one  suture  (Czerny,  Kelly);  Legueu  places  his  stitches  as  Guyon  in 
nephropexy,  doing  a  sort  of  hammock  suspension  of  the  uterus.1 

Pozzi  fixes  the  uterus  with  a  continuous  suture. 

Others  pass  their  sutures  vertically,  inserting  two  sutures,  one  to  the  right 
and  the  other  to  the  left  of  the  median  line  (Zinsmeister),  or  three,  one  in  the 
middle,  on  line  with  the  inferior  angle  of  the  abdominal  incision,  and  two 
lateral  (Faucon). 

It  has  been  advised  to  insert  a  pessary  or  do  vaginal  tam- 
poning after  the  operation  in  order  to  support  the  uterus  for 
some  days.  This  appears  to  us  to  be  useless. 

In  women  after  the  menopause,  Harris  has  advised  fixing  the  body  of  the 
uterus  in  the  substance  of  the  uterine  muscle.  He  sutures  the  edge  of  the 
incision  of  the  parietal  peritoneum  right  around  the  uterus  at  the  junction  of 
body  and  cervix.  Then  he  draws  the  f  undus  of  the  uterus  down  toward  the 
umbilicus,  denudes  the  anterior  face  and  fixes  it  to  the  fibrous  layers  of  the 
wall.2 

1  Voir  Hartmann,  Chirurgie  des  organes  geniio-urinaires  de  I'  homme,  Paris,  G.  Stein- 
heil,  1904 

2  Philander  A.  Harris,  Intramural  Sequestration  and  Fixation  of  the  Corpus  and 
Fundus  Uteri.     Am.  J.  ofObst.,  N.  Y.,  1910,  T.  II,  p.  36. 


396  ABDOMINAL   OPERATIONS   FOR   DISPLACEMENTS 

Results. — The  early  results  are  good.  The  operation  is  one 
of  the  safest  in  abdominal  surgery.  The  remote  results  should 
be  viewed  from  the  triple  point  of  view,  orthopedics,  therapeutics 
and  obstetrics. 

From  the  orthopedic  point  of  view,  the  results  are  poor  in 
cases  where  the  operation  has  been  done  to  remedy  a  simple 
retrodeviation  of  the  uterus ;  they  are,  however,  of  no  use  when 
the  hysteropexy  has  been  done  for  a  retrodeviation  complicating 
a  prolapse,  if  one  does  not  at  the  same  time  do  a  reconstruction 
of  a  solid  pelvic  floor. 

From  the  therapeutic  point  of  view,  they  are  equally  good  if 
the  deviation  constitutes  the  whole  trouble;  unfortunately,  it  is 
rare  to  have  to  operate  for  simple  non-complicated  deviations  as 
these  deviations  most  often  give  rise  to  no  functional  trouble. 
The  therapeutic  result  of  the  hysteropexy  will  depend  to  a  great 
extent  on  the  treatment  applied  to  the  troubles  which  complicate 
the  deviation.  If  the  adhesion  is  not  very  tight,  it  will 
elongate  and  constitute  a  band  which  may  cause  an  intestinal 
obstruction.1 

The  operations  of  uterine  fixations  are  most  often  done  in 
women  who  have  not  yet  arrived  at  the  menopause  and  hence  it 
is  useful  to  follow  the  remote  results  on  the  obstetrical  future. 

Andrews  has  had  395  cases  of  pregnancies  after  hysteropexy.2 

In  these  395  pregnancies  there  have  been  36  abortions,  or 
9  per  cent. ;  it  is  certain  that  many  of  these  abortions  have  been 
of  criminal  intent;  note  one  fact  that  in  some  cases  after  one 
abortion  there  have  been  several  pregnancies  at  term  (Negri, 
Olshausen,  Sanger) ;  nine  of  these  pregnancies  terminated  in  pre- 
mature labor. 

In  the  189  cases  published  with  details,  Andrews  found  10 
transverse  presentations,  three  breech,  three  uterine  ruptures, 
and  16  Cesarean  sections. 

The   combined  results   of  Noble,   Milaender,   Kustner  and 

1  Wallace,  in  order  to  prevent  this  complication  sutures  the  peritoneum  of  the  utero- 
vesical  cul-de-sac  below  the  point  of   the  hysteropexied  uterus.     Arthur  Wallace,  A 
Modification  in  the  Performance  of  Ventral  Fixation  of  the  Uterus.    Journal  of  Obst. 
and  Gyn.  of  British  Empire,  Aug.,  1907. 

2  Henry  R.  Andrews,  On  the  Effect  of  Ventral  Fixation  of  the  Uterus  on  Subsequent 
Pregnancy  and  Labor  Based  on  Analyses  of  395  Cases.     Journal  of  Obst.  and  Gyn.  of 
British  Emvire,  1905,  T.  II,  p.  97.     Consult  also:  Hysteropexy  and  its  Effect  on  Preg- 
nancies Following.     Ann.  de  Gyn.,  1904,  p.  225;  Seigert,  Zeilschr.  fur  Geb.  und  Gyn., 
1905,  T.  LV,  p.  383. 


ANTERIOR  ABDOMINAL   HYSTEROPEXY 


397 


Montandon  show  a  total  of  386  pregnancies  with  44  abortions, 
nine  premature  labors,  and  87  pathological  labors.1 

It  appears  that  the  operation  leads  to  a  fair  number  of  normal 
pregnancies.  One  point  is  established  and  that  is  that  these 
complications  are  in  relation  with  the  manner  in  which  the 
operation  has  been  executed  and  that  they  are  more  pronounced  in 
proportion  as  the  fixation  of  the  organ  is  more  solidly  fixed  and  the 
nearer  it  is  fixed  to  its  fundus  or  posterior  face. 

In  a  general  way,  one  finds  the  cervix  situated  high  up  above 
the  promontory;  during  labor,  uterine  contractions  are  directed 
toward  the  sacrum  instead  of  following  the  axis  of  the  pelvis. 
By  reason  of  the  fixation  of  the  fundus  of  the  uterus,  the  expan- 
sion of  the  anterior  wall  is  prevented ;  the  anterior  wall  is  hyper- 
trophied,  but  it  is  folded  back  on  itself  and  forms  a  hard  mass 
above  the  symphysis  (Fig.  340) ;  the  uterus  only  dilates  at  the 


FIG.  340. — Pregnancy  in  a  uterus  fixed  to  the  anterior  abdominal  wall. 

expense  of  its  posterior  wall  and  takes  on  an  irregular  shape. 
The  dystocia  observed  are  the  consequence  of  these  uterine 
deformities ;'  the  extreme  thinning  of  the  undisturbed  posterior 
wall  is  perhaps  also  the  cause  of  inertia  uteri  which  has  followed 
Cesarean  section  in  a  certain  number  of  cases. 

In  consideration  of  these  complications,  it  will  be  understood 
why  the  pregnancies  of  patients  who  have  had  hysteropexy 
done  should  be  carefully  watched.  If  from  the  commencement 

1  Montandon,  Abdominal  Hysteropexy  or  Intraperitoneal  Shortening  of  the  Round 
Ligaments.     These  de  Geneve,  1907,  No.  160. 


398  ABDOMINAL   OPERATIONS   FOR   DISPLACEMENTS 

there  are  violent  pains,  if  the  uterus  dilates  asymmetrically,  its 
cervix  being  displaced  upward  and  backward,  there  should  be  no 
hesitation;  as  soon  as  the  seventh  month  is  reached  open  the 
abdomen  and  break  down  the  adhesions  in  order  to  permit  the 
uterus  to  develop  regularly.  If  the  seventh  month  is  passed 
wait  until  term.  At  this  period  endeavor  to  break  down 
adhesions,  which  will  permit  of  the  immediate  elevation  of 
the  fundus,  the  replacing  of  the  cervix  and  the  accouchement 
per  vias  naturales;  if  this  breaking  down  of  adhesions  is  im- 
possible do  a  Cesarean  section.  Elizabeth  Hurden1  has  published 
five  cases  of  the  breaking  down  of  adhesions  at  term,  with  no 
maternal  mortality  and  a  fetal  mortality  of  two. 

Indications  have  been,  above  all,  applied  to  retrodeviations  if 
they  appear  to  be  the  cause  of  varied  troubles  when  there  are 
no  accompanying  lesions  of  the  adnexa,  of  the  cervix,  or  of  the 
uterine  mucous  membrane  or  when  the  congestive  phenomena 
appear  to  be  caused  or  at  least  kept  up  by  the  circulatory  dis- 
turbance resulting  from  the  retrodeviation.  It  has  been  prac- 
tised as  a  complementary  operation  after  a  vagino-perineal  plastic 
operation  in  order  to  remedy  a  retroflexion  complicating  a 
prolapse;  after  a  unilateral  removal  of  the  diseased  adnexa  in 
order  to  maintain  the  uterus  in  a  good  position  and  to  prevent 
it  adhering  behind  to  the  raw  surfaces  of  the  pelvic  floor;  after 
curettage  or  an  amputation  of  the  cervix  in  a  patient  with 
metritis  and  retroflexion. 

Condamin  has  applied  it  to  the  treatment  of  uterine  ante- 
flexion;  the  fixation  of  the  uterine  body  in  a  fairly  high  position 
redresses  the  flexion  and  causes  the  painful  symptoms  to  cease.2 

2.  Indirect  Hysteropexy. 

H.  A.  Kelly  fixes  the  uterus  by  means  of  the  tubo-ovarian 
ligaments,  Olshausen  by  the  internal  portion  of  the  round 
ligaments,  Winiwarter  by  the  anterior  face  of  the  broad  ligaments, 
etc.  All  these  procedures  should  be  abandoned  to-day  for  that 
procedure  with  some  modifications  which  has  been  adopted  by 

1  Elizabeth  Hurden,  Dystocia  Following  Ventral  Fixation  of  the  Uterus.     Amer.  J.  of 
Obst.,  1907,  T.  II,  p.  24. 

2  Condamin,  Anterior  Abdominal  Hysteropexy  in  the  Treatment  of  Anteflexion  of 
the  Uterus.     Arch,  provinc.  de  Chir.,  1896,  p.  233. 


INDIRECT  HYSTEROPEXY 


399 


Doleris,  Richelot,  Gilliam,  Mayo  and  ourselves.1  The  opera- 
tion consists  essentially  in  a  shortening  of  the  round  ligaments, 
after  median  incision  of  the  abdomen,  with  inclusion  in  the 
substance  of  the  abdominal  wall  of  a  part  of  their  length.  It  is 


FIG.  341. — The  round  ligament  is 
drawn  through  a  buttonhole  made  in 
the  rectus  muscle. 


FIG.  342. — Suture  of  the  round  liga- 
ments in  front  of  the  internal  portion 
of  the  recti  muscles. 


the  procedure  that  removes  them  the  least  from  their  natural 
state  that  has  become  known  as  physiological  hysteropexy 
(Doleris) . 

1  Doleris,  La  Gynecologie,  Paris,  1898,  p.  494.  Fumey,  Treatment  of  Retrodeviations 
by  Doleris  Method.  Th.  de  Paris,  1900.  Gouin,  Advantages  of  Hysterectomy  from 
the  Point  of  View  of  Obstetrics.  Th.  de  Paris,  1904-1905,  No.  25  et  la  Gynecologie, 
Paris,  Aug.,  1905,  p.  289.  Gilliam,  Round  Ligament  Ventrosuspension  of  the  Uterus. 
Am.  J.  of  Obst.,  N.  Y.,  1900,  T.  XLI,  p.  299.  Ferry,  Valeur  compared  de  hysteropexy 
mediate.  Th.  de  Paris,  1905-1906,  No.  202.  Harold  Barker,  Results  of  Mayo's  Modifica- 
tion of  Gilliam's  Operation  for  Shortening  the  Round  Ligaments.  Boston  Med.  and  tiurg. 
Jour.,  Sept.  2,  1909,  p.  322.  Chevrier,  Ann.  de  Gyn.,  Paris,  1910,  p.  257.  Poullet, 
Tendinous  Hysteropexy.  Congres  fran(ais  de  Chirurgie,  1908,  p.  293,  passes  through  a 
hole  made  in  the  anterior  fold  at  the  broad  ligament,  a  band  detached  from  the  tendon  of 
the  rectus  abdominis.  He  unites  it  to  the  round  ligament  and  then  sutures  the  tendin- 
ous band  to  the  pubis. 


400  ABDOMINAL   OPERATIONS   FOR   DISPLACEMENTS 

Operation. — The  commencement  of  the  operation,  freeing  of 
adhesions,  and  redressing  of  the  uterus  is  as  usual,  only  the 
mode  of  fixation  differs  from  that  we  described  in  the  technic 
of  direct  hysteropexy. 

Each  round  ligament  is  seized  3  or  4  cm.  from  the  cornu,  a 
point,  where  even  in  cases  that  it  is  little  developed,  it  is  a  firm 
and  resistant  cord;  a  chromicized  catgut  is  passed  around  it. 
Strongly  retracting  the  anterior  lip  of  the  incision  made  in  the 
anterior  aponeurosis,  the  surgeon  inserts  a  pair  of  Kocher's 
forceps  in  between  the  fibers  of  the  rectus  muscle  and  perforates 
with  it  the  peritoneum.  He  then  takes  the  long  catgut  ends  which 
encircle  the  round  ligament  and  draws  with  them  through  the 
muscular  buttonhole  the  round  ligament.  The  two  ligaments 
are  sutured  together  in  front  of  the  muscle.  The  abdominal 
wall  is  reestablished  in  its  different  planes,  and  we  are  careful 
to  take  the  round  ligaments  with  the  suture  that  unites  the 
anterior  aponeuroses  so  as  to  obtain  a  complete  fixation  of  parts. 

Indications  and  Results. — Indications  are  those  already 
given  for  direct  abdominal  hysteropexy.  The  results  are  ex- 
cellent from  the  orthopedic  point  of  view,  and  are  as  good  as  those 
of  direct  hysteropexy.  They  are  very  superior  to  it  from  the 
point  of  view  of  pregnancy,  as  this  means  of  fixation  does  not 
interfere  with  the  progress  of  the  gravid  uterus. 


FIG.  343.  —  Shortening  of  the  round  ligaments  by  transverse  folding. 


3.  Intra-abdominal   Shortening  of    the    Round  Ligaments. 

The  procedures  concerned  in  intra-abdominal  shortening 
of  the  round  ligaments  are  very  numerous;  they  may  be  classed 
in  three  groups. 


INTRA-ABDOMINAL  SHORTENING  OF  THE  ROUND  LIGAMENTS     401 

1.  Simple  Folding  of  the  Round  Ligament. — Wylie  makes  a 
transverse  fold  and  fixes  it,  after  having  denuded  its  concave 
surface  (Fig.  343) ;  Ruggi  does  it  vertically  with  the  convexity 


FIG.  344. — Shortening  of  the  round  ligaments  by  vertical  folding. 


FIG.  345. — Shortening  of  the  round  ligaments  by  folding  up. 

upward  (Fig.  344).     Formerly  we  gathered  up  the  round   liga- 
ment into  one  mass,  like  an  accordeon  with  a  tacked  stitch 

(Fig.  345). 


26 


402 


ABDOMINAL   OPERATIONS  FOR   DISPLACEMENTS 


2.  Folding  up  and  Fixation  to  the  Anterior  Wall  of  the  Uterus. 

— Polk  denudes  the  internal  surface  of  the  round  ligaments  about 

20  or  25  cm.  from  their  uterine  end.     He  brings  them  together 

in  front  of  the  uterus  and  sutures  one  to  the  other  and  then  to  the 

anterior  surface  of  the  uterus. 


FIG.  346. — Folding  up  and  fixation  of  the  round  ligaments  to  the  anterior  surface  of  the 

uterus. 


FIG.  347. — The  round  ligament  is  drawn  backward  through  a  hole  in  the  broad  ligament. 

Palmer  Dudley  denudes  an  ovale  with  its  large  axis  vertical, 
in  the  middle  part  of  the  anterior  face  of  the  uterus;  the  round 
ligaments  are  sutured  together  and  to  this  surface. 

Menge  draws  out  a  loop  of  the  round  ligament  and  inserts 
it  at  the  level  of  the  orifice  of  the  inguinal  canal,  which  brings 


INTRA-ABDOMINAL  SHORTENING  OF  THE  ROUND  LIGAMENTS     403 

the  uterine  cornu  in  contact  with  it.  He  sutures  the  two  sides 
of  the  loop  of  the  ligament  together  and  then  to  the  anterior 
surface  of  the  uterus. 

3.  Folding  up  of  the  Round  Ligaments  and  Fixation  of  the 
Fold  to  the  Posterior  Surface  of  the  Uterus. — This  fixation  back- 
ward has  been  done  in  different  ways.  When  one  has  passed 
the  folded  round  ligament  above  the  upper  border  of  the  broad 


FIG.  348. — The  two  round  ligaments  are  drawn  together  behind  the  uterus. 

ligament,  it  is  passed  through  a  buttonhole  in  the  latter  and 
fixed  to  the  middle  or  lateral  part  of  the  posterior  surface  of  the 
uterus  and  in  the  former  case  the  two  ligaments  may  be  sutured 
together. 

Baldy's1  procedure  is  the  most  universally  employed.  It 
was  described  for  the  first  time  in  1892  and  it  has  at  last  been 
taken  up  again.  In  France  Dartigues  and  Caraven2  practised 
it  with  success. 

Raising  the  upper  border  of  the  broad   ligament  with  two 
fingers  of  the  left  hand,  take  a  pair  of  forceps  and  perforate  the 

1  J.  M.  Baldy,  Treatment  of  Retro-uterine  Displacements.     Surg.,  gyn.  and  obstet., 
Chicago,  1909,  T.  VIII,  p.  421. 

2  Dartigues  and  Caraven. 


404 


ABDOMINAL   OPERATIONS   FOR   DISPLACEMENTS 


ligament  from  behind  forward,  in  the  avascuJar  portion,  near  the 
border  of  the  uterus,  and  below  the  utero-ovarian  ligament. 
Then  seize  the  round  ligament  about  3  cm.  from  the  uterine  cornu 
(Fig.  347) .  The  forceps  draws  through  the  hole  in  the  broad  liga- 
ment the  loop  formed  by  the  round  ligament.  The  operation 
is  concluded  by  suturing  the  two  round  ligaments  together  and 
then  to  the  posterior  surface  of  the  uterus. 


Fig.  349. — Suture  of  the  two  round  ligaments  together  and  to  the  posterior  aspect  of  the 

uterus. 


4.  Cuneohysterectomy. 

Thiriar  and  Jonnesco  have  carried  out  the  procedure  known  as  anterior 
Cuneohysterectomy1  for  retroflexion. 

The  operation  consists  in  diminishing  the  length  of  the  anterior  wall  of  the 
uterus.  After  incision  of  the  peritoneum,  2  or  3  cm.  of  this  wall  are  denuded 
retracting  the  bladder  with  the  inferior  part  of  the  incised  serous  membrane. 
Two  curved  transverse  incisions  circumscribe  an  ellipse  on  the  denuded  area 
whose  small  axis  measures  1  1/2  to  2  cm.  and  the  large  transverse  axis  is 
about  the  width  of  the  organ,  without,  however,  reaching  its  borders  so  that 
the  vessels  there  are  not  injured.  A  cuneiform  segment  is  resected  at  this 

1  International  Congress  of  Gynecology  and  Obstetrics,  Brussels,  1892,  p.  512.  Jon- 
nesco, Surgical  Works,  1899,  p.  11. 


CUNEOHYSTERECTOMY 


405 


level  and  comprises  the  whole  thickness  of  the  muscular  wall  without  taking 
up  the  mucous  membrane.  Three  or  four  catgut  sutures  unite  the  lips  of  the 
incision;  a  second  layer  of  sutures  brings  together  the  lips  of  the  peritoneal 
incision. 


FIG.  350.— Cuneohysterectomy.      Denu-  FIG.  351.— Cuneohysterectomy. 

dation  and  passage  of  stitches.  Operation  terminated. 


FIG.  352.  FIG.  353. 

Shortening  of  the  Utero-sacral  ligaments. 


We  may  compare  Pestalozza's1  operation  with  this  one.  At  the  upper 
limit  of  the  inferior  segment  of  the  uterus,  Pestalozza  incises  on  the  anterior 
surface  the  serous  membrane  and  the  subjacent  muscular  layer.  He 
separates  the  flap  with  his  finger  as  far  as  the  level  of  the  vesical  dome  and 
then  passing  a  suture  through  the  anterior  surface  of  the  anteflexed  uterus,  he 

1  Pestalozza,  Per  la  cura  Operativa  della  Retroflessione  Uterina.  Atti  delta  Soc.  ital. 
d'obst.  e.  gin.,  T.  XII,  and  Montuoro,  Zenlr.-Bl.  f.  Gyn.,  1910,  p.  497. 


406  ABDOMINAL   OPERATIONS   FOR   DISPLACEMENTS 

traverses  the  middle  of  the  flap.  A  series  of  secondary  sutures  are  inserted 
laterally  as  far  as  the  broad  ligaments  so  as  to  completely  close  up  the 
denuded  surface. 

By  passing  the  sutures  more  or  less  high  up  on  the  anterior  surface  of  the 
uterus,  we  obtain  a  more  or  less  extensive  area  with  the  flap  and  we  can  thus 
determine  the  degree  of  anteflexion  accordingly. 

5.  Intraabdominal  Shortening  of  the  Utero-sacral  Ligaments. 

The  uterus  having  been  drawn  forward  and  upward  the  utero-sacral  liga- 
ments are  rendered  tense  and  one  or  more  sutures  are  placed  on  these  liga- 
ments; the  sutures  are  passed  from  without  in  about  2  cm.  from  the  uterus 
in  order  to  pass  again  through  the  ligament  from  within  outward  at  the  same 
distance  from  the  rectum.  When  tied,  we  get  a  folding  of  the  ligament, 
which  is  thus  shortened  (Figs.  352  and  353). 


CHAPTER  VI. 

SOME  RARE   ABDOMINAL  OPERATIONS. 

Summary. — Obliteration  of  the  pouch  of  Douglas. — Ligature  of  the 
uterine  artery. — Ligature  of  the  hypogastric  veins. — Reduction  of  uterine 
inversion . — Cystopexy . 

1.  Obliteration  of  the  Pouch  of  Douglas. 

Marion,  who  invented  this  operation  for  certain  cases  of  prolapse  with 
exaggerated  deepening  of  the  pouch  of  Douglas,  advises  it  to  be  done  as 
follows:1 

The  abdomen  being  opened,  the  pelvis  emptied  of  its  intestines,  he  draws 
the  uterus  forward  and  then  proceeds  to  the  obliteration  of  the  pouch  of 
Douglas  by  means  of  four  purse-string  sutures  of  increasing  diameter  in  the 
peritoneal  cul-de-sac. 

In  order  to  insert  these  sutures  he  begins  by  seizing  the  floor  of  the  cul-de- 
sac  with  forceps  which  draw  it  upward,  and  then  places  completely  around  it 
a  subperitoneal  suture  which  he  ties  after  having  taken  off  the  forceps.  The 
first  suture  is  drawn  upward  in  its  turn,  which  permits  of  placing  a  second, 
and  one  can  then  successively  dispose  of  a  series  of  four  or  five  sutures  accord- 
ing to  the  depth  of  the  cul-de-sac. 

These  sutures  should  take  hold  not  only  of  the  peritoneum  on  the  pos- 
terior surface  of  the  vagina  or  the  uterus,  but  equally  on  the  sides,  the  serous 
membrane  that  clothes  the  pelvis  below  the  white  line. 

The  insertion  of  the  deepest  stitches  is  quite  a  delicate  undertaking;  to  do 
it  best,  the  operator  should  take  hold  of  the  peritoneum  with  a  long  pair  of 
forceps  for  holding  tampons  and  then  insert  into  the  fold  thus  produced  the 
suture  needle.  The  inserted  sutures  should  go  as  high  as  the  posterior  face  of 
the  uterus.  The  only  precaution  is  to  guard  against  completely  perforating 
the  coats  of  the  rectum. 

Thus  the  pouch  of  Douglas  is  obliterated.  The  cervix  is  drawn  back- 
ward and  adhesions  between  it  and  the  rectum  and  peritoneum  of  the 
postero-lateral  portions  of  the  excavations  are  produced  (Figs.  354  and  355). 

This  procedure,  to  us,  seems  above  all  applicable  to  "false  prolapse," 

1  Rousseau,  Treatment  of  Certain  Cases  of  Prolapse  by  Obliteration  of  the  Pouch  of 
Douglas.  Th.  de  Paris,  1908-1909,  No.  7. 

407 


408 


SOME    RARE   ABDOMINAL   OPERATIONS 


FIG.  354. — Obliteration  of  the  pouch  of  Douglas. 


FIG.  355. — Obliteration  of  the  pouch  of  Douglas. 


LIGATURE  OF  THE  UTERINE  ARTERY 


409 


those  cases  in  which  there  is  a  real  hernia  of  the  pouch  of  Douglas,  sometimes 
confused  with  true  prolapse.  It  is  good,  we  believe,  to  combine  it  with  a 
posterior  colporrhaphy. 

2.  Ligature  of  the  Uterine  Artery  by  the  Abdominal  Route. 

* 

The  uterine  artery,  the  ligature  of  which  has  been  advised  in  certain  cases 
where  atrophy  of  tumors1  is  desired,  may  be  done  in  two  ways: 

1.  At  the  Level  of  the  Ovarian  Fossa  (Hartmann  and  Fredet). — The  land- 
mark in  this  operation  is  the  constant  relationship  of  the  uterine  artery  to  the 
ureter  at  the  level  of  the  little  fossa  of  the  ovary. 


FIG.  356. — The  patient  is  placed  in  the  Trendelenburg  position  at  an  angle  of  45  degrees. 
The  figure  shows  the  relation  of  the  uterine  artery  to  the  ureter  in  the  ovarian  fossa. 

The  hypogastric  artery,  up  against  the  osseous  wall  of  the  pelvis,  behind 
the  ureter  or  in  part  covered  over  by  it,  gives  off  three  anterior  branches,  the 
obturator,  the  umbilical  and  the  uterine,  which  separate  in  front  of  the  ureter 
under  the  peritoneum  which  clothes  the  floor  of  the  ovarian  fossa. 

1  Hartmann  and  Fredet,  The  Atrophying  Ligatures  in  the  Treatment  of  Uterine 
Tumors."  Ann.  de  Gyn.,  Paris,  1898,  T.  I,  pp.  110-306. 


410 


SOME    RARE   ABDOMINAL   OPERATIONS 


The  uterine  artery  which  comes  off  either  high  or  low,  or  in  common  with 
the  umbilical  artery,  always  appears  in  front  of  the  urinary  canal.  This 
constitutes  an  excellent  landmark  for  the  finding  of  the  artery  and  its  origin 
(Fig.  356).  If  there  is  some  doubt  in  the  event  of  our  finding  two  vessels, 
both  are  tied  or  the  common  utero-umbilical  trunk  is  tied.  Never  risk  by  an 
incision  in  the  ovarian  fossa  the  injury  of  the  obturator,  which  lies  higher 
and  more  parietal  than  the  two  arteries  we  have  mentioned. 

We  will  now  describe  how  the  operation  is  done: 

The  patient  having  been  placed  in  the  Trendelenburg  position,  the 
ovary  is  lifted  up  with  a  pair  of  Museux's  forceps  and  the  ovarian  fossa  is 


FIG.  357. — This  figure  is  the  exact  reproduction  of  that  of  Altuchoff. 
The  two  drawings  represent  a  vertical  antero-postericr  section  of  the  bread  ligament 
about  the  mid  point  of  the  length  of  the  tube.  (I.  o.,  ovarian  ligament;  /.  F.,  Fallopian 
tube;Z.  r.,  round  ligament;  TO,  partition  forming  a  sort  of  mesentery  to  the  round  ligament ; 
V.,  uterine  vein;  U.,  ureter;  A.,  uterine  artery;  v.  u.,  bladder.  To  the  left,  the  Fig.  I 
shows  the  parts  in  partition;  to  the  right,  Fig.  II,  shows  that  on  drawing  forward  the 
round  ligament,  the  mesentery  is  drawn  with  it  and  the  uterine  artery  which  normally 
in  A.  comes  after  traction  to  lie  in  front  of  the  round  ligament  at  A.  In  order  to  catch 
the  artery  follow  the  course  jf  the  arrow. 

exposed.  At  this  level,  below  the  psoas,  may  be  seen  the  ureter  by  trans- 
ference. Parallel  to  it  and  a  little  in  front  an  incision  is  made  in  the  perit- 
oneum of  the  ovarian  fossa.  Seizing  between  forceps  the  lips  of  the  incision, 
separate  the  peritoneum  backward  a  little  with  a  grooved  director  and  about 
3  cm.  below  the  brim  of  the  pelvis,  the  uterine  and  umbilical  arteries  at  the 
point  where  these  vessels  separate  anteriorly  from  the  ureter. 

Nothing  is  simpler  once  the  artery  is  recognized  than  to  pass  a  blunt 
needle  and  suture  below  it  and  tie  it.  Some  fine  silks  unite  the  peritoneum, 
loose  enough  to  avoid  compressing  the  subjacent  ureter;  then  the  abdomen 
is  closed  in  the  usual  way. 

2.  Across  the  Broad  Ligament  (Altuchoff). — This  procedure  is  based  on 
the  following  anatomical  data : 

There  exists  in  the  substance  of  the  broad  ligament  a  sort  of  partition 
which  mounts  from  its  base  toward  the  round  ligament,  doubling  the  anterior 


LIGATURE  OF  THE  HYPOGASTRIC  VEINS  411 

layer  of  the  broad  ligament.  The  uterine  artery  is  adherent  to  this  sort  of 
partition  and  follows  it  when  it  is  drawn  forward  (Fig.  357). 

In  order  to  ligature  the  uterine  artery  by  this  procedure,  lifting  up  the 
tube,  the  round  ligament  is  drawn  forward;  parallel  to  this  and  immediately 
behind  it,  we  make  an  incision  of  about  3  cm.,  the  external  end  of  which  ter- 
minates about  1  cm.  from  the  innominate  line. 

The  grooved  director  is  made  to  enter  the  substance  of  the  broad  ligament, 
following  its  anterior  layer,  which  reinforced  by  the  "cellular  mesentery  of 
the  round  ligament,"  gives  a  fairly  resistant  point  of  support.  At  a  depth  of 
12  to  16  mm.  one  comes  across  the  uterine  artery; when  recognized,  nothing 
is  simpler  than  to  tie  it  fairly  high  up.  The  ureter  lies  below  and  behind  the 
artery;  it  will  not  be  injured. 

3.  Ligature  of  the  Hypogastric  Veins. 

This  ligature  has  been  advised  and  carried  out  with  success  since  1902 
by  Trendelenburg  in  a  case  of  puerperal  pyemia.  Freund  and  Bumm  had 
already  tried1  without  success  to  stop  the  puerperal  processes  from  going 
beyond  the  uterus  by  tying  the  utero-ovarian  veins.  Their  course  being 
•checked  is  explained  by  the  fact  that  phlebitis  of  the  hypogastric  veins  is 
three  time  more  frequent  than  that  of  the  utero-ovarian  ones,  21  as  opposed 
to  7  (Trendelenburg),  which  was  confirmed  by  Lenhartz. 

1.  Extraperitoneal  Route. — By  an  iliac  incision  the  peritoneum  is 
separated  and  then  the  hypogastric  vessels  are  looked  for. 

Transperitoneal  Route. — The  transperitoneal  route,  which  is  easier  and 
which  permits  furthermore  of  tying  if  necessary  the  utero-ovarian  veins,  is 
preferred  by  Vineberg.2  After  opening  of  the  abdomen  in  the  median  line, 
the  operation  will  depend  upon  whether  it  is  necessary  to  tie  or  not  the  utero- 
ovarian  veins  at  the  same  time  as  the  hypogastric  veins.  In  the  former  case, 
cut  the  utero-ovarian  veins  between  two  ligatures  and  prolong  the  peritoneal 
incision  downward  along  the  length  of  the  hypogastric  vessels.  Enlarge  this 
incision  with  the  fingers  and  we  have  the  large  pelvic  vessels  exposed  to  view. 
Nothing  is  simpler  than  to  tie  the  internal  iliac  vein,  which  is  to  be  found  on 
the  right  behind  and  to  the  outside  of  the  artery  and  on  the  left  to  the  inside 
of  the  artery.  If  the  utero-ovarian  veins  are  healthy,  make  an  oblique  inci- 
sion on  the  posterior  surface  of  the  broad  ligaments  like  that  of  Wertheim  in 
his  radical  operation  for  cancer.  Then  separate  the  edges  of  the  peritoneal 
incision  and  we  find  that  we  have  a  liberal  access  to  the  base  of  the  ligament 
and  to  the  large  pelvic  vessels  contained  in  it. 

1  Trendelenburg,  Munch,  med.  Wooh.,  1902,  T.  XIII. 

2  Vineberg,  Ligation  of  Pelvic  Veins  for  Puerperal  Pyemia,  Amer.  J.  of  Obst.,  N.  Y., 
19Qj>,  T.  I,  p.  412. 


412  SOME    RARE   ABDOMINAL   OPERATIONS 

4.  Reduction  of  Uterine  Inversion  by  the  Abdominal  Route. 

Gaillard  Thomas, after  he  has  opened  the  abdomen, introduces  his  index- 
finger  into  the  inverted  uterus,  and  then  guides  along  it  a  dilating  forceps 
which  enlarges  the  cervix  and  renders  taxis  easy. 

This  method,  which  enables  us  by  sight  and  palpation  to  find  out  the  state 
of  contraction  of  the  cervix  and  of  the  form  and  extent  of  the  adhesions, 
appears  a  priori  to  be  the  operation  of  choice. 

In  reality  it  has  given  few  good  results  by  reason  of  the  difficulty  in  dilat- 
ing the  cervical  ring  and  because  of  the  necessity  of  often  splitting  it.  It  is 
simpler  to  operate  by  the  vaginal  route. 

In  1898  Everk  proposed  a  mixed  procedure  by  abdomino-vaginal  route. 
He  opens  the  abdomen,  splits  the  anterior  wall  of  the  uterus  as  far  as  the 
bladder,  and  if  the  reduction  is  impossible  he  splits  the  posterior  wall  as  far 
as  the  insertion  of  the  vagina  and  then  reduces  it  with  the  vaginal  hand  on 
the  fundus  of  the  uterus.  He  concludes  by  suturing  the  anterior  and  pos- 
terior uterine  incisions,  then  fixes  the  organ  to  the  anterior  abdominal  wall. 

5.  Abdominal  Cystopexy. 

Abdominal  cystopexy  has  been  done  by  a  certain  number  of  operators. 
Tuffier  fixes  the  bladder  by  its  extraperitoneal  part  above  the  pubis.  Byford 
fixes  it  on  a  line  with  the  inguinal  rings ;  Laroyenne  commences  by  doing  an 
abdominal  hysteropexy  and  then  sutures  the  postero-inferior  wall  of  the 
bladder  to  the  anterior  face  of  the  uterus,  and  its  anterior  wall  to  the  abdom- 
inal wall  below  the  zone  of  fixation  of  the  uterus.1 

De  Vlaccos,  Dumoret2  and  Chiaventone  do  an  intraperitoneal  fixation. 
Chiaventone,  after  incision  of  the  vesico-uterine  fold,  separates  the  bladder 
from  the  uterus  and  from  the  vagina  up  to  a  point  where  the  dense  connective 
tissue  takes  the  place  of  the  loose  tissue.  He  finds  that  he  is  at  the  level  of  the 
interureteral  ligament  which  he  takes  up  and  stitches  to  the  anterior  surface 
of  the  uterus  about  1  cm.  above  the  anterior  vaginal  fornix.  He  closes  the 
incision  of  the  vesico-uterine  cul-de-sac  and  finishes  by  doing  an  anterior 
abdominal  hysteropexy.3 

All  these  procedures  are  abandoned  to-day. 

1  Laroyenne,  Treatment  of  Prolapse  by  Suspension  of  the  Uterus  and  Bladder  from 
the  Abdominal  Wall.     Ann.  de  Gyn.,  Paris,  1900,  T.  II,  p.  366. 

2  Terrier,    Anterior    Abdominal   Cystopexy.     Report   on   Observations   of    Vlaccos, 
Dumoret  and  Turner.     Bull,  et  Mem.  de  la  Soc.  de  Chir.,  Paris,  1890,  p.  454. 

3  Chiaventone,  Cystopexy  in  Gynecology.     Ann.  de  Gyn.,  Paris,  1902,  T.  I,  pp.  282 
and  385. 


PART  IV. 

THERAPEUTIC  INDICATIONS  IN  DISEASES  OF  THE 
GENITAL  SYSTEM  OF  WOMAN. 


CHAPTER  I. 

TREATMENT  OF  INFLAMMATORY  LESIONS  OF  THE  UTERUS  AND 

ADNEXA. 

Summary. — Metritis.  Evolution  of  pathogenic  conception  and  treat- 
ment.— T.  prophylactic,  T.  curative  of  acute  metritis,  of  chronic  metritis 
(general  and  local  treatment). — Indications  of  treatment  in  acute  and  chronic 
inflammation  of  the  adnexa. 

1.  Treatment  of  Metritis. 

The  treatment  of  metritis  is  far  from  being  definitely  estab- 
lished; divergence  of  surgeons  in  their  opinions  on  this  special 
point  of  gynecological  therapeutics  points  to  the  obscurity  of  the 
nature  of  this  affection. 

Here,  as  everywhere,  therapeutics  have  always  been  closely 
allied  to  the  pathogenic  conception  and  different  modes  of  treat- 
ment, gradually  abandoned,  reflect  faithfully  the  different 
theories  that  inspired  them. 

Forty  years  ago,  in  a  case  of  metritis  one  saw  only  the  local 
expression  of  a  general  state :  herpetic  eruptions  of  cervix,  scrof- 
ulous1 and  rheumatic  metritis,  etc.,  were  described. 

With  metritis  was  ranged  congestion  and  uterine  subinvo- 
lution,  without  exact  knowledge  of  the  lesions  one  was  treating. 
Therapeutics  participated  in  the  uncertainty.  It  consisted 
mainly  in  a  line  of  general  treatment  in  keeping  with  the  sup- 
posed diathesis  of  the  patient,  and  of  applying  various  local 
applications  to  the  cervix. 

Modern  bacteriological  work  and  the  idea  of  infection  abruptly 
simplified  the  conception  and  treatment  of  the  inflammation  of 

1  Martineau,  Clinical  Treatise  on  the  Uterine  Affections,  Paris,  1879. 

413 


414     TREATMENT   OF   INFLAMMATORY   LESIONS   OF   THE    UTERUS 

the  uterus.  The  term  metritis  became  synonymous  with  in- 
fectious lesion  of  the  uterus  and  the  treatment  once  clearly 
grasped,  had  as  its  simple  object,  the  disinfection  of  the  endome- 
trium.  Various  and  varied  means  have  been  tried  to  this  end, 
varying  from  simple  antiseptic  treatment  to  curettage,  which 
represents  the  most  energetic  expression  of  antiseptic  treatment. 

Latterly  gynecologists  have  come  to  the  conclusion  that  the 
role  of  infection  has  been  exaggerated  and  we  have  a  division 
into  metritis  and  infective  metritis,  and  then  a  variety  of  path- 
ological conditions  known  as  false  metritis  (Doleris),  simple 
chronic  metritis,  non-infective,  hypoplastic  metritis  (Doderlein), 
uterine  sclerosis  (Richelot),1  etc. 

These  non-infective  metrites  or  pseudo-metrites  spring  from 
a  variety  of  causes.  Generally,  it  is  a  local  cause  (tears  of  the 
cervix,  prolapse,  uterine  deviations,  tumors  of  the  uterus,  etc.). 

Infection  may  have  been  the  original  cause;  the  primary 
microbe  disappears,  but  the  lesion  continues  to  evolve  and  finally 
forms  the  disease  without  it. 

At  other  times  it  comes  from  a  general  cause  such  as  neuro- 
arthritis,  eventually  leading  to  a  sclerosis  of  the  uterus.  Finally 
more  recently,  our  attention  has  been  drawn  to  lesions  of  the 
mesometrium,2  either  an  insufficiency  of  muscular  tissue  com- 
bined with  chlorosis  or  such  affections  as  tuberculosis  or  typhoid 
fever,  or  a  congestion  or  stasis  brought  about  by  sexual  excesses, 
onanism,  defective  hygiene,  or  circulatory  troubles  due  to  arterio- 
sclerosis.3 

The  existence  of  these  non-infective  metrites  is  to-day  suffi- 
ciently demonstrated,  but  it  is  often  difficult  to  distinguish 
them  from  chronic  infective  metrites.  From  the  clinical  point  of 
view,  the  differences  are  often  minimal  and  at  times  do  not  exist. 
An  etiological  research  from  an  interrogation  of  the  patient  is 
often  very  uncertain ;  there  only  remains  the  bacteriological  exami- 
nation which  may  also  be  uncertain. 

It  is  certain  that  we  should  diminish  in  one's  mind  the  role 

1  Richelot,  Surgery  of  the  Uterus. 

2  Theilhaber  and  Meier,  Zur  Anatomic,  Pathologie  und  Terapie  der  chronischen  Endo- 
metritis.     Arch.f.  Gyn.,  Berlin,  1908,  T.  LXXXVI,  p.  628.     Hirsch,  Arch.  f.  path.  Anat.f 
Berlin,  1909,  T.  CXCVI,  fasc.  3. 

3  Palmer  Findley,  Arteriosclerosis  of  the  Uterus  as  a  Casual  Fact  in  Uterine  Hemor- 
rhage (Am.  J.  ofObst.,  July,  1905,  p.  71).     Brooke  M.  Anspach,  Metrorragia  myopathica. 
Univ.  of  Penn.  Med.  Bull.,  Feb.,  1906,  p.  322.     R.  L.  Dickinson,  Intractable  Menorrhagia 
of  Arteriosclerosis  of  the  Uterus,  Brook.  Med.J.,  1906,  T.  XX,  p.  45. 


TREATMENT  OF  METRITIS  415 

of  infection  and  not  at  the  same  time  to  exaggerate  the  number 
and  importance  of  those  pseudo-metrites.  Nevertheless  it  is 
certain  that  from  the  point  of  view  of  practice  there  exist  a  certain 
number  of  cases  where  antiseptic  medication,  with  the  object  of 
destroying  infective  agents,  is  quite  useless  as  these  do  not  exist. 
Finally,  from  the  therapeutic  point  of  view,  we  should  take 
account  of  concomitant  lesions,  tears  of  the  cervix,  elevations, 
prolapse,  etc.,  which  if  they  do  not  cause  metritis,  favor,  more  or 
less,  its  development  and  contribute  toward  its  support. 

I.  Prophylactic  Treatment. 

For  infective  metritis  the  indications  for  treatment  are  quite 
distinct.  We  must  cure  the  vulvo-vaginal  infections,  which  may 
ascend  toward  the  uterus.  We  should  do  every  gynecological 
exploration  under  cover  of  strictest  asepsis.  Aseptic  precautions 
in  pregnant  women  have  a  great  importance;  the  majority  of  post- 
puerperal  metrites  result  from  some  infraction  of  asepsis  during 
an  exploration  or  intervention  during  labor. 

The  retained  placental  remains  may  be  perhaps  the  direct 
cause  of  infection  as  they  favor  at  least  the  invasion  of  pathogenic 
agents. 

Again  from  another  point  of  view,  we  should  take  note  of  the 
state  of  the  husband's  urethra.  A  number  of  metrites  are  not 
only  caused  by,  but  kept  up  by,  gleet  and  the  treatment  of  this 
gleet  is  one  of  the  most  important  prophylactic  means  we  possess. 
Young  men  should  be  warned  of  the  danger  to  their  wives  from 
a  neglected  and  very  small  discharge. 

In  non-infective  metritis,  in  which  the  pathogenic  is  still 
unknown,  prophylaxis  has  not  advanced  much.  The  general 
hygiene  as  adopted  by  the  woman  is  the  capital  point.  The 
advantage  of  sufficient  rest  in  bed  after  an  accouchement  abor- 
tion, of  abstention  from  exaggerated  or  abnormal  sexual  stimula- 
tion, after  menstrual  troubles,  etc.,  is  generally  admitted.  There 
is  nothing,  however,  definitely  established  in  the  foregoing. 

II.  Curative  Treatment. 

Curative  treatment  differs  according  as  we  have  to  deal  with 
an  acute  or  chronic  metritis. 

Acute  Metritis. — We  will  only  deal  here  with  two  types  of 


416     TREATMENT   OF   INFLAMMATORY   LESIONS   OF   THE    UTERUS 

acute  metritis,  gonorrhea!  and  septic,  of  which  the  latter  is 
exemplified  generally  in  puerperal  metritis. 

Gonorrheal  Metritis. — The  treatment  is  not  extensive.  The 
patient  is  put  to  bed  and  given  complete  repose.  Give  vag- 
inal injection  of  permanganate  of  potash  (1  in  5,000  to  1  in 
20,000). 

Secure  a  daily  evacuation  of  the  intestine.  If  there  is  acute 
pain,  put  ice  on  the  abdomen,  and  prescribe  morphia  sup- 
positories. In  every  case  abstain  from  the  least  intrauterine  inter- 
vention by  reason  of  the  possible  invasion  of  tubes  and  per- 
itoneum. 

Septic  Metritis. — In  septic  metritis,  where  puerperal  infection 
is  the  most  frequent,  repose,  diet,  light  laxatives,  application  of 
ice  to  the  abdomen,  antipyretics,  general  antiseptics  as  collargol 
or  electrargol,  and  vaginal  injections  have  been  advised.  But, 
contrary  to  the  rules  of  treatment  in  acute  gonorrhea,  the  local 
action  on  the  uterus  is  our  first  thought.  The  means  proposed 
to  act  on  this  organ  are  three:  Intrauterine  irrigations,  curettage 
and  hysterectomy. 

Intrauterine  irrigations  which  may  be  repeated  one  to  three 
times  in  twenty-four  hours  constitute  the  simplest  of  the  means 
we  possess.  In  slight  cases,  they  give  excellent  results,  above 
all  if  one  is  careful  not  to  combine  with  them  any  tamponing  of 
the  uterus  which  generally  blocks  it,  but  to  do  drainage  of  the 
cavity  with  a  simple  rubber  drain  instead. 

In  acting  thus  we  do  not  pretend  to  destroy  the  micro- 
organisms of  the  uterine  cavity,  but  we  avoid  stagnation  and 
diminish  the  phenomena  of  absorption.  If  the  intrauterine 
irrigations  are  inefficacious,  we  should  not  wait,  but  go  on  to 
curetting  of  the  uterus  which  is  often  indicated  by  another 
cause  such  as  the  existence  of  a  retained  product  of  the 
placenta. 

There  has  been  much  discussion  over  the  indications  of  curet- 
ting in  cases  of  puerperal  metritis. 

A  certain  number  of  gynecologists  particularly  in  Germany 
are  opposed  to  it. 

Its  utility  in  cases  of  partial  or  complete  retention  of  the  pla- 
centa seems  to  us  to  be  indisputable.  In  all  cases  of  septic  lochia 
with  fever,  we  may  always  have  recourse  to  it.  The  fear  of 


TREATMENT  OF  METRITIS  417 

destroying  the  protective  membrane  of  defense  or  of  not  evacuat- 
ing all  the  intrauterine  germs  should  not  arrest  the  surgeon. 

The  somewhat  rare  complications  we  have  observed  are 
nothing  in  proportion  to  the  considerable  number  of  patients 
whose  fever  ceases  on  curettage,  free  irrigation  and  drainage  of 
the  uterine  cavity. 

When  the  intrauterine  injections  and  curettage  are  powerless, 
the  question  of  hysterectomy  occurs  to  us.  Theoretically  it  is 
indicated  after  failure  of  simple  treatment  when  the  uterus  is 
the  sole  starting-point  of  the  complications.  When  there  are  no 
infective  foci  outside  it,  neither  peritonitis  nor  more  remote 
lesions,  caused  by  the  transportation  of  septic  emboli  to  some 
distance,  in  a  word,  when  life  is  in  immediate  danger  by  reason 
of  the  existence  of  an  infection  in  the  uterus. 

Unfortunately,  in  practice  it  is  often  difficult  to  be  sure  that 
life  is  actually  in  danger;  a  patient  who  seems  lost  is  better 
the  next  day,  others  who  seem  to  be  doing  very  well  sud- 
denly show  signs  of  being  much  worse.  The  secondary  met- 
astatic  deposits  are  not  easy  to  discover.  Hesitation  is,  there- 
fore, necessary  before  intervention.  The  results  of  the  opera- 
tion are,  however,  not  very  brilliant.  Christeanu,1  who  has 
collected  137  cases,  finds  a  mortality  of  63  per  cent.,  larger  than 
for  hysterectomy  after  confinement  at  full  term,  64  per  cent.,  and 
also  larger  than  that  after  abortion,  42.2  per  cent.  It  must  also 
be  understood  that  few  surgeons  are  in  favor  of  the  radical  opera- 
tion. If  resorted  to,  total  hysterectomy  is  preferable  to  subtotal, 
as  the  infective  lesions  often  spread  to  the  cervix.  As  to  the  route 
to  follow,  it  varies  greatly;  the  vaginal  route  has  been  objected 
to  because  the  uterus,  soft  and  friable,  is  easily  torn  by  traction 
of  the  teethed  forceps ;  this  -objection  fails,  if  in  place  of  using 
teethed  forceps  we  use  large  forceps  with  flat  extremities  of  the 
same  variety  as  cyst  forceps.  The  abdominal  route,  however, 
most  merits  our  preference  because  it  permits,  in  cases  where  it 
appears  necessary,  of  our  operating  on  the  veins  of  the  pelvis, 
tying  and  excising  those  that  are  affected  with  suppurative 
phlebitis,  an  important  point,  as  juxta-uterine  venous  suppura- 
tion, is  far  from  rare  in  the  cases  that  we  are  dealing  with. 

1  Cristeanu,  Hysterectomy  and  Acute  Puerperal   Infection.     Revue  de  Gynec.  et  de 
Chir.  Abd.,  Paris,  1904,  p.  617. 
27 


418     TREATMENT   OF   INFLAMMATORY   LESIONS   OF   THE    UTERUS 

Chronic  Metritis. — The  treatment  of  chronic  metritis  should 
be  general  and  local  at  the  same  time. 

General  Treatment. — The  importance  varies  according  to  the 
case.  Even  when  we  are  dealing  with  a  chronic  infectious 
metritis  we  should  not  leave  it  completely  on  one  side. 

We  should  avoid  all  cases  of  congestions  in  the  lower  pelvis, 
and  constipation  in  particular;  this  latter  may  be  treated  by  use 
of  enemas  and  laxatives.  Repose  is  one  of  the  first  indications, 
and  rest  in  bed,  if  the  symptoms  still  show  a  certain  character 
of  acuteness  or  if  there  are  any  hemorrhages,  or  rest  on  a  sofa  if  the 
patient  is  a  chronic;  we  thus  avoid  fatigue,  walking  or  standing 
for  any  period  of  time.  Sexual  congress  should  be  absolutely 
forbidden. 

Wearing  a  belt  or  appropriate  corset,  lifting  up  the  lower 
abdomen  and  preventing  the  intestinal  mass  from  pressing  on 
the  uterus  is  also  of  use. 

To  this  hygienic  treatment  add  an  internal  medication,  which 
is,  according  to  the  case,  simply  tonic,  antiarthritic  or  anti- 
lymphatic.  Mineral  water  treatment  may  be  of  great  use,  if  it  is 
thought  necessary  to  act  on  the  general  condition.  The  choice 
of  a  resort  depends  above  all  on  the  nature  of  general  symptoms, 
which  are  superadded  to  the  genital  troubles.1 

Local  Treatment. — Local  treatment  of  chronic  metritis  con- 
sists of  a  series  of  agents,  which  we  will  simply  enumerate,  and 
•we  have  mentioned  the  technic  of  their  execution  earlier  in  this 
work.  We  will  see  later  which  agent  is  to  be  preferred  accord- 
ing to  the  type  of  metritis  we  are  dealing  with. 

The  vaginal  injections  are  currently  employed.  Remember 
the  importance  of  the  position  of  the  patient  and  temperature 
of  the  injection.  The  nature  of  the 'fluid  employed  is  only  of  a 
relative  interest. 

As  vaginal  dressings  we  use  tampons  of  iodoform  or  salicylic 
gauze  steeped  in  neutral  or  slightly  iodized  glycerine.  We  may 
also  use  ovules  with  a  glycerine  base.  This  last  named  merits, 
as  a  local  application  to  the  cervix  and  vagina,  a  reputation  due 
to  its  hydragogic  properties. 

Cauterizations  of  the  cervix  with   thermocautery  or  chemical 

1  See  Mineral  Water  Treatment. 


TREATMENT  OF  METRITIS  419 

agents  (tincture  of  iodine,  chloride  of  zinc,  nitrate  of  silver,  etc. ) 
may  be  of  use.  We  should  also  use  intrauterine  therapeutic 
agents  which  are  applied  in  various  forms :  intrauterine  pencils, 
tamponings,  uterine  lavage,  chemical  cauterization  and  disin- 
fection with  touching  up  of  the  parts  with  formol  in  a  solution 
of  30-50  per  cent.1  Remember  the  importance  of  preliminary 
dilatation  which  may  besides  constitute  the  principal  stage  of 
the  treatment  in  rendering  the  uterine  muscle  supple  and  securing 
easy  drainage  of  the  uterine  cavity. 

Curettage,  formerly  regarded  as  the  last  resort  in  treatment 
of  metrites,  has  now  restricted  indications  for  its  use,  also  better 
determined  ones. 

~Let  us  mention  in  conclusion  that  the  different  varieties  of 
amputation  of  the  cervix  and  more  particularly  amputation  by 
Schroder's  procedure  or  a  modified  form  of  the  same,  and 
finally  hysterectomy,  vaginal  or  abdominal,  which  may  be  indi- 
cated in  some  exceptional  cases. 

Such  are  the  local  means  at  the  disposal  of  the  surgeon  in 
the  treatment  of  metritis.  We  must  make  a  choice  from  these, 
according  to  the  form  of  metritis  we  are  dealing  with. 

In  a  general  way,  metrites  in  their  primary  phase,  in  particular 
those  which  follow  on  the  puerperal  state,  are  accompanied  by 
notable  lesions  of  the  cavity  of  the  body;  later,  when  the  disease 
is  characterized  above  all  by  abundant  leucorrheal  discharges,  it 
appears  to  be  entrenched  above  all  in  the  region  of  the  cervix. 
The  treatment  should  be  directed  to  the  body  or  cervix  according 
to  the  case. 

In  gonorrheal  metritis  of  still  recent  growth,  if  gonococci  are 
found  in  the  uterine  discharge,  dilate  the  uterus  and  follow  with 
liberal  washing  out  with  lukewarm  solution  of  permanganate  of 
potash,  in  strength  varying  from  1  in  4000  parts  to  1  in  1000 
parts. 

At  a  more  advanced  period,  if  the  gonococci  are  rare  or  dis- 
appeared, we  should  have  recourse  to  cauterization  with  silver 

1  Menge  recommends  this  agent  very  warmly.  He  rolls  a  thin  layer  of  wool 
around  the  sound,  steeps  it  in  formol  and  applies  both  ends  successively  to  the  mucous 
membrane;  the  first  to  drain  the  mucous  membrane,  the  second  to  change  it.  A  piece 
of  iodoform  gauze  is  afterward  inserted  into  the  vagina  to  obtain  a  cauterization  of  its 
mucous  membrane.  The  application  should  be  renewed  at  the  end  of  eight  days  and 
then  at  longer  intervals.  (C.  Menge,  Die  Therapieder  chronischen.  Endometritis  in  der 
alleemeinen  Praxis.  Arch,  fur  Gyn.,  Berlin,  1901,  T.  LXIII,  p.  291.) 


420     TREATMENT   OF   INFLAMMATORY   LESIONS   OF   THE   UTERUS 

nitrate  (1  per  cent,  to  5  per  cent.),  chloride  of  zinc  (10  per  cent.), 
tincture  of  iodine,  etc. 

Always  do  a  preliminary  dilatation  before  these  cauteriza- 
tions. Between  these  cauterizations  we  may  apply  medicated 
pencils. 

In  non-specific  infective  processes  at  their  onset  or  having  be- 
come secondary,  the  treatment  varies  according  to  the  anatomo- 
clinical  conditions  we  are  brought  face  to  face  with. 

Hemorrhagic  metritis  justifies  curettage  of  which  it  constitutes 
the  triumph.  Instillations  of  chloride  of  zinc  give  also  excellent 
results  in  these  hemorrhagic  forms  and  may  even  cure  these  cases 
where  curettage  has  failed,  while  uterine  atmokausis  has  equally 
given  numerous  successes  in  infective  hemorrhagic  metritis,  but 
the  difficulty  of  its  application  and  above  all  of  regulating  this 
very  energetic  therapeutic  agent,  determined  us  to  reject  its  em- 
ploy. One  should  choose  then  between  cases  for  curettage  or  for 
instillations  of  chloride  of  zinc,  after  a  preliminary  dilatation. 

In  leucorrheal  forms,  intrauterine  treatment  has,  for  a  time, 
been  abused,  such  as  the  scraping,  injecting  or  uselessly  cauteriz- 
ing of  the  uterine  cavities.  As  Richelot  very  wisely  remarks,  the 
majority  of  cases  of  purulent  leucorrhea  is  connected  with  lesions 
of  the  cervix,  so  they  must  be  treated. 

In  slight  cases,  with  enlarged  cervix  or  with  slight  ectropion, 
a  cure  may  often  be  very  simply  obtained  by  the  combination  of 
light  cauterizations  with  nitrate  of  silver  or  applications  of 
iodine,  etc.,  and  dressings  to  the  vagina. 

In  grave  cases  we  should  have  recourse  to  a  more  energetic 
treatment  and  make  use  of  cauterizations  with  Filhos'  caustic. 
If  the  cervix  shows  characteristic  lesions  of  sclero-cystic  degenera- 
tions, we  should,  without  hesitating,  amputate  it  by  one  of  the 
anaplastic  procedures  we  have  described. 

In  the  lesions  which  are  manifestly  not  infective  and  are  some- 
times described  under  the  names  of  congestion  and  uterine 
sclerosis,  curettage  and  intrauterine  treatment  is  not  often  of 
great  use. 

For  uterine  congestion  in  virgins  rest  in  bed,  during  men- 
struation and  abstention  in  the  intervals  from  violent  exercise 
(horse  riding,  bicycle  and  abuse  of  dancing)  constitute  the  base  of 
the  treatment  (Siredey).  The  uterine  medication  (hydrastis 


TREATMENT  OF  METRITIS  421 

canadensis,  viburnum  prunifolium,  piscidia  erythrina  and  above 
all  quinine  sulphate  in  doses  of  16  to  24  grains)  render  signal 
services  (Richelot). 

In  a  young  woman,  hot  vaginal  injections  at  50°  C.,  of  from 
5  to  10  liters,  given  gently  under  low  pressure,  diminish  greatly 
the  pains  and  hemorrhage.  Glycerine  applications,  electricity 
and  massage  render  service.  Intrauterine  therapeutic  agents 
have  hardly  any  use  in  the  hemorrhagic  forms. 

In  all  cases  general  treatment  has  a  great  importance.  One 
should  avoid  all  cause  of  pelvic  congestion,  such  as  constipation, 
by  giving  enemas  and  laxatives  so  as  to  get  a  good  motion  daily, 
but  no  true  purgation.  Alcoholic  drinks,  meat  in  excess,  iron 
preparations  are  useless  and  often  harmful.  Baths,  in  particular 
alkaline  ones,  friction  with  horse  hair  gloves  and  general  massage, 
in  short,  anything  that  stimulates  the  circulation  is  indicated.  A 
point  which  should  never  be  rejected  is  to  endeavor  to  diminish 
the  pressure  on  the  uterus  and  consequently  it  is  necessary  to 
proscribe  corsets  which  constrict  the  waist  and  force  the  abdom- 
inal contents  toward  the  pelvis.  On  the  contrary  advise  the  use 
of  a  belt  or  corset  which  strongly  elevates  the  lower  pelvis.  A 
thermal  cure  will  certainly  do  much  good.  Neris  and  Luxeuil 
are  useful  for  nervous  patients;  the  former  of  these  is  specially 
good  for  those  patients  in  whom  nervous  erethismus  is  excessive 
and  the  latter  for  those  in  whom  a  nervous  condition  is  combined 
with  gastrointestinal  troubles  such  as  entero-colitis ;  on  the 
contrary,  if  the  general  troubles  of  nutrition  are  marked,  recom- 
mend Vichy,  Royat,  Chatel-Guyon,  Vittel. 

All  these  agents  are  very  suited  to  cases  that  are  plainly 
sclerosis  of  the  uterus.  One  can  in  the  hemorrhagic  forms  add 
to  it  local  treatment  and  in  particular  dilatation  of  the  uterus. 
The  operations  to  produce  atrophy,  subvaginal  amputation  and 
above  all  supravaginal  amputation  of  the  cervix,  render  useful 
service  in  advanced  cases.  In  more  particularly  rebellious  cases, 
with  great  uterine  enlargement  as  also  in  cases  of  alteration  of  the 
mesometrium  united  with  arteriosclerosis,  this  treatment  may  be 
able  to  check  it,  and  the  necessity  of  a  more  serious  intervention 
may  be  necessary  to  prevent  complication  and  particularly 
hemorrhage.  It  is  for  such  cases  that  complete  destruction  of  the 
mucous  membrane  by  intrauterine  vaporization  has  been  recom- 


422     TREATMENT   OF   INFLAMMATORY   LESIONS   OF   THE    UTERUS 

mended;  hysterectomy  with  a  better  technic  and  more  certain 
results  appears  to  us  to  be  preferable;  we  have  recourse  to  it  in 
the  circumstances. 

Let  us  add  in  conclusion  that  in  whatever  form  of  metritis 
we  are  dealing  with,  it  is  always  essential  to  treat  the  accompany- 
ing lesions.  To  do  this,  operations,  sometimes  complex,  such  as 
curetting,  amputation  of  the  cervix,  colporrhaphy  perineorrhaphy 
and  hysteropexy,  may  be  carried  out  at  the  same  operation,  and  is 
the  only  means  of  procuring  a  definite  cure,  as  a  treatment  which 
is  directed  solely  against  the  inflammatory  would  only  give  a 
temporary  amelioration. 

2.  Treatment  of  Inflammation  of  the  Adnexa. 

The  treatment  of  inflammation  of  the  adnexa  has  passed 
through  very  varied  stages.  Up  to  the  appearance  of  antisepsis 
lesions  of  the  adnexa,  the  pathology  of  which  was  little  known, 
belonged  to  the  domain  of  medicine.  Gradually  intervention 
was  carried  out  in  certain  periuterine  collections  appearing  during 
the  course  of  the  puerperium. 

The  fact  that  one  could  antisepticaJly  open  the  peritoneal 
cavity  without  danger,  changed  the  face  of  the  situation  and 
almost  all  lesions  of  the  adnexa  appeared  to  justify  extirpation. 
Tait  was  one  of  the  protagonists  of  this  radical  surgery;  he  did 
not  hesitate  in  a  unilateral  adnexitis  to  remove  the  tube  and 
ovary  of  the  healthy  side,  believing  that  later  its  infection  was 
almost  inevitable. 

It  is  useless  to  recall  the  discussions  which  arose  in  extra- 
medical  circles  over  the  incontestable  abuse  of  removal  of  the 
adnexa.  These  discussions  have  lost  to-day  their  primary 
bitterness,  while  time  shows  that  more  and  more,  by  a  sort 
of  reaction,  the  tendency  of  surgeons  is  to  practice  in  the  most 
extensive  measure  possible,  conservative  operations.  In  the  last 
few  years  there  has  been  a  movement  in  Germany  against 
all  operative  treatment,  even  against  conservative  operations. 
Amann,  who,  in  1899,  operated  24  per  cent,  of  women  with  in- 
flammation of  the  adnexa,  in  1901  did  only  4.5  per  cent,  and 
considers  the  operation  as  indicated  in  lesions  of  a  tuberculous 
nature.  A  certain  number  of  gynecologists  have  rallied  to  this 


TREATMENT  OF  INFLAMMATION  OF  THE  ADNEXA  423 

view,  to  a  certain  extent.  Treub  had  already  expressed  the 
same  opinion. 

In  America  and  in  France,  on  the  contrary,  the  operation  is 
still  the  order  of  the  day. 

We  will. study  the  treatment  of  inflammation  of  the  adnexa 
in  the  acute  and  chronic  state. 

I.  Acute  Adnexitis. 

The  treatment  of  acute  inflammation  of  the  adnexa,  putting 
aside  suppuration,  is  of  the  simplest.  The  alarming  manifesta- 
tions at  the  commencement  are  in  relation  to  the  peritoneal 
retention  which  accompanies  acute  salpingitis.  Again  these 
inflammatory  peri-adnexal  foci  have  generally  a  natural  ten- 
dency to  spontaneous  cure.  It  suffices  to  aid  nature  in  her  cure. 
In  slight  cases,  rest  in  bed  combined  with  hot  vaginal  injections 
and  daily  evacuations  of  the  bowels  by  enemas  or  mild  laxatives, 
a  low  diet  is  sufficient  treatment.  If  there  is  acute  pain,  the  con- 
stant application  of  ice  to  the  abdomen,  and  sometimes  analgesics, 
are  indicated. 

Generally  the  trouble  slowly  disappears,  the  patient  gets  well 
or  is  left  with  a  chronic  inflammation  of  the  adnexa.  Exception- 
ally general  troubles  become  worse,  the  fever  and  pain  increase, 
and  a  purulent  collection  forms  in  the  neighborhood  of  the  uterus. 
The  surgeon  should  then  intervene  and  incise  the  collection  on 
the  most  accessible,  either  by  colpotomy,  which  is  generally 
employed,  or  sometimes  by  an  iliac  incision.  The  choice  be- 
tween the  vaginal  route  and  the  iliac  route  is  subordinated  to 
the  results  obtained  by  the  physical  examination. 

II.  Chronic  Adnexitis. 

In  the  treatment  of  chronic  adnexitis,  the  first  question  which 
occurs  to  us  is:  when  should  we  adopt  medical  treatment,  and 
when,  on  the  contrary,  should  the  surgeon  intervene  ? 

If  the  clinical  history  of  the  disease  (former  brief  attacks  of 
pelvic  peritonitis,  pains,  fever,  etc.)  and  the  physical  examination 
(large  fixed  mass)  makes  one  suspect  the  existence  of  suppurating 
lesion  there  should  be  no  possible  hesitation;  we  must  operate. 


424     TREATMENT   OF   INFLAMMATORY   LESIONS   OF   THE   UTERUS 

If  there  is  absolutely  no  suppurative  lesion,  we  should  wait 
and  try  medical  treatment.  A  certain  number  of  objections 
have  been  made  to  the  conservative  treatment:  the  long  duration, 
the  danger  of  after  attacks,  and  the  number  of  failures.  These 
criticisms  have  been  a  little  exaggerated.  Every  time,  practi- 
cally, that  we  do  not  think  that  we  are  dealing  with  a  suppurative 
lesion,  we  advise  medical  treatment. 

The  base  of  this  treatment  is  the  combination  of  rest  in  bed 
and  hot  vaginal  injections.  Rest  is  the  fundamental  principle. 
It  does  not  consist  of  half  resting,  but  of  complete,  absolute  rest 
in  bed  or  on  a  sofa.  The  employment  of  half  measures,  as  for 
example  in  allowing  the  patient  non-fatiguing  occupation, 


FIG.  358. — Pincus'  apparatus. 


should  be  absolutely  condemned.  The  question  is,  can  the 
patient  carry  out  this  treatment  ?  Hot  injections  of  say  48  to  50° 
C.  and  the  application  of  moist  heat  to  the  abdomen  and  warm 
baths,  either  salt  or  alkaline,  constitutes  the  treatment  in  addi- 
tion to  rest.  It  has  also  been  advised  to  use  very  hot  enemas, 
which  act  like  vaginal  injections  and  give  as  good  results.  One 
should  pay  attention  naturally  to  the  regularity  of  the  digestive 
functions  and  to  treat  the  general  state  by  appropriate  means. 

A  certain  number  of  German  gynecologists  state  they  get  good 
results  by  vaginal  packing,  and  passing  hot  air  into  it. 


TREATMENT  OF  INFLAMMATION  OF  THE  ADNEXA 


425 


Treatment  by  this  packing  is  derived  from  the  old  columniza- 
tion  of  the  vagina  and  the  methodical  tamponing  by  which  one 
tries  to  secure  a  sustained  pressure  on  the  diseased  parts.  One 
of  the  best  means  of  doing  this  is  with  Pincus1  apparatus. 
The  patient  is  placed  on  the  table  with  the  pelvis  and  lower  limbs 
raised  (see  ~Fig.  359).  Then  insert  into  the  vagina  an  india- 
rubber  bulb  resembling  the  Gariel  pessary.  This  bulb  is  united 
by  a  rubber  tube  to  an  elliptical  glass  receptacle,  which  has  three 
tubes  and  three  corresponding  balls.  One  communicates  directly 
with  the  air,  the  second  with  an  insufflator,  and  the  third  with  a 
second  india-rubber  ball  full  of  mercury  (Fig.  358).  By  elevat- 
ing this  last,  one  gently  squeezes  500  grams  of  mercury  into  the 
vaginal  bulb,  gradually  increasing  the  weight,  but  never  going 
beyond  1200  to  1500  grams. 

This  compression  is  left  for  one,  two  or  three  hours  or  longer. 


FIG.  359. — Technic  of  vaginal  packing. 

We  should  never  abruptly  bring  the  compression  to  an  end,  so  as 
to  avoid  pelvic  congestion  "in  vacuo."  Now  we  employ  the 
insufflator.  As  the  vaginal  bulb  of  mercury  is  emptied  by  low- 
ering the  whole  apparatus,  air  is  injected,  and  finally  the  tap  is 
opened  to  allow  the  air  to  escape  gradually  in  its  turn  (Fig.  359). 

At  the  same  time  an  external  compression  is  made  on  the 
abdomen  with  a  weight  of  2500  grams  of  shot. 

The  heating  of  the  abdomen  helps  the  absorption  of  exu- 
dates.  This  is  carried  out  with  a  kind  of  hot-air  apparatus  which 

Pincus  (L.),  Belastungslagerung,  Wiesbaden,  1905. 


426     TREATMENT   OF   INFLAMMATORY   LESIONS   OF   THE    UTERUS 

encloses  the  whole  of  the  abdomen,  and  the  heat  is  generated  by 
electric  lamps,1  gas  heaters  or  alcohol  lamps.  In  order  to  per- 
mit the  hot  air  to  act  not  only  externally  on  the  abdomen,  but 
also  by  the  vagina,  a  tubular  speculum  is  inserted  which  con- 
sists of  practically  a  non-conductor  of  heat  (wood  or  hardened 
rubber) . 

The  air  enters  the  apparatus  at  a  temperature  of  100°  or  120°. 
The  sittings  which  last  15  minutes  at  the  beginning  are  progres- 
sively prolonged  to  three-quarters  of  an  hour.  The  skin  is 
dripping;  the  parts  of  the  body  in  the  apparatus  resemble  a 
boiled  crayfish,  and  an  abundant  discharge  occurs  by  the  cervix. 
It  is  advantageous  during  the  sitting  to  place  a  compress  soaked 
in  fresh  water  on  the  forehead. 

The  patient  should  only  have  a  sensation  of  pricking;  if  she 
complain  of  burns,  we  must  immediately  lower  the  temperature  by 
turning  off  the  source  of  heat.  As  soon  as  the  "seance"  is 
finished,  dry  the  patient  and  wrap  the  abdomen  in  hot  wool, 
and  cover  her  with  wroollen  blankets  so  as  to  retain  as  long  as 
possible  the  heat.  In  short,  we  substitute  an  intense  heat  and 
congestion  of  the  abdomen  for  the  old  cataplasm. 

Should  we  in  adnexitis  try  to  act  on  the  lesions  by  an  intra- 
uterine  treatment  ?  This  method  has  warm  partisans  and 
obstinate  adversaries.  Generally,  it  consists  of  dilatations 
followed  later  by  tamponing,  curettage,  or  by  catheterizing  the 
tubes.  It  has  even  been  said  that  a  pyosalpinx  might  be  evac- 
uated "per  vias  naturales. "  Anatomical  and  anatomo-patholog- 
ical  data  scarcely  permit  us  to  believe  in  this  and  it  is  held  that 
only  suppurating  intratubal  collections  should  be  removed. 
.There  are  cases  where  intrauterine  treatment  causes  improve- 
ment; the  endometritis  reacts  indirectly  on  the  adnexal  lesions. 
There  are  those  cases  in  which  the  tumefaction  is  not  properly 
speaking  formed  by  the  inflamed  adnexa,  but  consists  of  peri- 
toneal or  periuterine  exudates  which  proclaim  themselves  clin- 
ically by  a  diffuse  puffiness  of  the  fornices  without  one  being 
able  to  discern  a  well  defined,  limited  tumor.  For  patients  with 

1  Polano,  Eine  neue  Methode  der  Behandlung  chronischen  Beckenexsudate.  Centr.- 
Bl.f.  Gyn.,  Leipzig,  1901,  p.  857,  et  Zur  Anwending  der  Heissluftherapie  in  der  Gynako- 
logie.  Ibidem,  1902,  p.  961.  Kehrer,  Beitr.  zur  Behandlung  chronischen  Beckenexsu- 
date. Ibidem,  1901,  p.  1409.  Jung,  Beitr.  z.  Heissluftherapie  bei  Beckeneiterungen. 
Munch,  med.  Woch.,  1905,  p.  2521. 


TREATMENT  OF  INFLAMMATION  OF  THE  ADNEXA  427 

lesions  of  this  kind,  uterine  dilatation  followed  by  prolonged  drain- 
age of  the  cavity  is  indicated ;  following  on  this  drainage,  one  may 
see  the  uterus  gradually  lose  its  congestion,  return  to  its  former 
state  and  the  periuterine  lesions  gradually  retrogress. 

Quite  recently,  Aulhorn  stated  he  got  good  results  even  in 
pyosalpinx.  *  With  a  syringe  holding  2  1/2  c.c.,  and  a  flat, 
slightly  curved  cannula  provided  with  several  lateral  orifices, 
he  injects  with  moderate  pressure  into  the  uterine  cavity.  The 
liquid  used  should  be  bactericidal,  specially  antigonococcic,  and 
at  the  same  time  should  not  come  into  contact  with  the  perito- 
neum, as  nitrate  of  silver  would  cause  a  severe  irritation.  The 
liquid  used  should  be  argentamine  (a  solution  of  phosphate  of 
silver  in  some  ethylic  diamine)  in  a  2  per  cent,  solution. 

At  first  one  should  inject  only  11/2  c.c.  of  the  solution  as  the 
injection  causes  cramp-like  pains;  after  several  injections  the 
patient  suffers  much  less  and  the  whole  contents  of  the  syringe 
may  be  injected  with  sufficient  force  to  make  the  liquid  pene- 
trate into  the  tubes.  The  results  were  excellent.  Eighty-two 
per  cent,  of  the  patients  were  completely  relieved  of  their  troubles 
in  4  to  5  weeks.1 

Whatever  the  treatment  employed,  even  if  the  tuberculous 
cases  are  left  on  one  side  and  where  operation  is  always  required, 
surgical  intervention  is  nevertheless  indicated  when  a  grave  con- 
dition threatens  life,  or  when  acute  attacks  follow  on  a  chronic 
lesion,  or  when  conservative  methods  have  failed,  and  there  is  no 
change  in  objective  or  subjective  symptoms.  We  should  also 
take  into  account  the  social  condition  of  the  patient  and  the  life 
she  leads.  Also  in  spite  of  numerous  attempts,  carried  out  latterly, 
to  enlarge  the  domain  of  non-operative  treatment,  we  believe 
that  in  a  great  number  of  cases  one  will  be  obliged  to  have  recourse 
to  the  removal  of  diseased  organs.  When  the  necessity  of  a 
bilateral  removal  is  indicated,  we  should  remove  the  uterus  at  the 
same  time  as  it  is  useless  to  preserve  it  and  it  may  lead  to  various 
discharges. 

The  operation  is  not,  however,  necessarily  destructive  and 
the  surgeon  should  endeavor  to  preserve  all  or  part  of  the  dis- 
eased adnexa  in  a  certain  number  of  cases.  We  have  seen  how 

1  Aulhorn,   Die  Behandlung  entztindlicher  Adnexerkrankungen  mit  intra-uterinen 
Injectionen.     Arch.  f.  Gyn.,  Berlin,  1910,  T.  XC,  p.  213. 


428     TREATMENT   OF   INFLAMMATORY   LESIONS   OF   THE    UTERUS 

a  certain  number  of  conservative  operations  is  at  our  disposition 
(simple  freeing  of  adhesions,  followed  or  not  followed  by  salpingo- 
pexy,  expression  of  the  tubes,  salpingostomy,  ignipuncture,  and 
partial  resection  of  the  ovary) . 

These  different  conservative  operations  may  give  success, 
and  pregnancies  may  develop  later;  but  the  number  of  these  is 
not  as  great  as  one  would  think  a  priori.  If  they  are  frequent 
after  freeing  of  the  adnexa,  ignipunctures  and  partial  restrictions 
of  the  ovary,  they  are  exceptional  after  salpingostomy. 

Also  in  obliterations  of  the  infundibulum  we  are  tempted  to 
systematically  remove  the  diseased  organ  and  remove,  at  the 
same  time,  the  uterus  if  there  are  bilateral  lesions.  The  preser- 
vation of  the  uterus  has  no  object  and  has  only  drawbacks;  it 
leaves  in  the  abdomen  a  bleeding  surface,  a  cornu  often  infected, 
and  a  deviated  organ;  the  enlarged  uterus  is  diseased  and  the 
origin  of  various  discharges,  of  a  sensation  of  bearing  down,  and 
of  pelvic  uneasiness ;  its  preservation  is  only  a  cause  of  complica- 
tions and  trouble. 

Latterly  following  Beuttner's  example,  we  have  combined 
the  removal  of  the  pyosalpinx  with  a  wedge  from  the  uterus  and 
conservation  of  one  or  two  ovaries.  The  early  results  have  been 
very  good;  but  our  observations  are  still  too  recent  in  order  to 
allow  us  to  formulate  a  definite  opinion  on  the  value  of  the 
procedure. 


CHAPTER  II. 

TREATMENT  OF  NEOPLASMS  OF  THE  UTERUS  AND  ADNEXA. 

Summary. — Uterine  fibromata  (general  indications  of  treatment;  Treat, 
palliative,  medical,  surgical;  Treat,  radical,  vaginal  and  abdominal  myo- 
mectomy,  hysterectomy,  vaginal  and  abdominal). — Fibromata  and  preg- 
nancies.— Malignant  tumors  of  the  uterus  (sarcoma  cancer,  Treat,  radical 
and  palliative). — Cancer  of  cervix  and  pregnancy. — Tumors  of  the  ovary. 

1.  Treatment  of  Uterine  Fibromata. 

Uterine  fibromata  (fibrous  bodies,  myomas,  fibromyomas,  etc.) 
are  tumors  whose  structure  resembles  that  of  uterine  tissue. 
They  are  benign  neoplasms,  in  this  sense  that  in  contradistinction 
to  cancer,  they  do  not  become  generalized  and  are  not  propagated 
to  the  glands.  They  are,  however,  tumors  for  which  an  operation 
is  often  enough  indicated  on  account  of  the  complications  they 
produce,  even  in  the  absence  of  any  secondary  degeneration. 
The  complications  are  various:  some  are,  so  to  speak,  directly 
in  connection  with  the  fibroma,  such  as  hemorrhages,  which  so 
frequently  accompany  them,  and  which  are  almost  constant, 
when  the  tumor  projects  into  the  uterine  cavity.  Others  are  the 
consequence  of  secondary  inflammatory  lesions,  and  particularly 
those  of  the  adnexa;  finally  others  result  simply  from  the 
progressive  growth  of  the  tumor,  its  enormous  size  and  the 
interference  it  causes  to  the  intra-abdominal  organs. 

These  considerations  explain  to  us  why  certain  fibromas 
should  be  operated  and  why  others  should  be  abandoned  to 
themselves.  Some  partisans  of  intervention  in  all  cases  invoke 
to  aid  their  ideas  the  benign  character  of  early  operation,  the 
possible  sarcomatous  transformation  of  the  tumor,  and  the 
extreme  gravity  of  a  late  hysterectomy.  It  is  certain  that  hesita- 
tion formerly  was  carried  to  an  extreme,  and  that  it  is  a  mistake 
to  await  the  menopause  at  any  price,  reckoning  with  retrogressive 
influence  on  the  myomas.  The  operation  is  often  necessary, 
even  when  menstruation  has  ceased. 

429 


430  TREATMENT   OF   NEOPLASMS   OF   THE    UTERUS 

But  between  these  exaggerated  opinions  there  is  a  happy 
medium.  To-day  the  majority  of  surgeons,  while  regarding 
operation  as  indicated  in  the  majority  of  cases,  think  that  station- 
ary fibromata  unaccompanied  by  hemorrhages,  pain,  compres- 
sion phenomena,  may  be  submitted  to  a  purely  palliative  treatment 
while  being  carefully  watched  so  as  to  be  always  ready  to  inter- 
vene in  any  case  where  a  change  in  the  evolution  of  the  tumor 
occurs. 

I.  Palliative  Treatment. 

Palliative  Medical  Treatment. — A  series  of  agents  have  been 
advocated  for  the  purpose  of  avoiding  operation.  Rest  in  bed 
during  hemorrhage,  leaving  off  a  too  tight  corset,  use  of  a  hypo- 
gastric  belt  and  hot  vaginal  injections  of  48°  to  50°  C.  have  in 
turn  been  recommended  to  lessen  congestion  of  the  pelvis  and 
all  have  their  use. 

There  are  also  certain  drugs.  Fluid  extract  of  hydrastis 
canadensis,  25  drops  two  or  three  times  a  day;  viburnum  pruni- 
folium,  piscidia  erythrina,  hamamelis,  virginica,  stypticine,  iodi- 
pine,  salypirine,  and  above  all  ergot,  the  systematic  employ  of 
which  was  suggested  by  Hildebrandt. 

Ergotine  may  be  given  by  mouth  or  rectum.  Generally  it  is 
prescribed  as  a  hypodermic  injection. 

Pozzi  advises  the  following  prescription : 

1$.     Ergotine,  grams  v 

Chloral  hydrat.,  grams  j 

Aqua  destill.,  grams  c. 

Inject  daily  12  drops  of  this  solution.  The  injections  should 
be  done  with  all  the  indispensable  aseptic  precautions,  either  into 
the  muscles  of  the  buttock  or  shoulder.  We  can  thus  obtain  an 
action  on  the  hemorrhage,  and  no  complications  of  intoxication 
are  observed,  but  pains  and  abscesses  are  frequent  enough. 
Treatment  is  long  and  painful,  and  gives  hardly  any  cures. 


TREATMENT  OF  UTERINE  FIBROMATA  431 

Chloride  of  soda  mineral  waters  (Salies-de-Bearn,  Briscous- 
Biarritz,  Salins  du  Jura,  Kreuznach,  etc.)  have  an  action  which  is 
sometimes  real  on  hemorrhages,  and  they  have  the  advantage  of 
stimulating  the  general  nutrition. 

Electricity  has  played  for  some  twenty  years  an  exaggerated 
role,  as  a  result  of  Apostoli's  work.  It  appears  to  act  in  intersti- 
tial fibromas,  which  still  participate  in  the  life  of  the  uterus.  It 
acts  essentially  on  hemorrhages,  and  also  on  the  pain ;  its  influence 
on  the  size  of  tumors  is  less  certain.  If  we  add  that  its  action  is 
not  always  harmless,  as  one  would  at  first  be  led  to  believe,  and 
that  patients  have  died  as  result  from  peritonitis,  perforation  of 
the  rectum  and  bladder,  it  will  be  understood  why  we  have 
reserved  its  application  and  that  we  have  had  recourse  to  it  only 
in  those  women  who  were  rebellious  to  all  operative  treatment, 
toward  the  approach  of  the  menopause  and  afflicted  with  inter- 
stitial fibromata  of  fair  volume  which  are  mainly  troublesome 
owing  to  the  hemorrhages  and  pain  they  cause. 

Latterly  we  have  had  recourse  to  X-rays  to  destroy  the  ovaries 
and  thus  bring  about  an  artificial  menopause.  Kronig  obtained 
amenorrhea  in  60  per  cent,  of  cases  and  oligomenorrhea  in  30 
per  cent.  The  indications  for  intervention  for  hemorrhagic 
myomas  may  be  thus  limited,  as  we  may  have  recourse  to  X-ray 
treatment  in  patients  who  are  blanched  with  loss  of  blood,  or  in 
any  fat  patients  or  in  those  with  bronchial  catarrh.  In  a  word, 
in  all  those  where  operation  indicates  a  particular  gravity.  We 
certainly,  by  these  means,  secure  a  reduction  in  the  results  of  the 
mortality  of  radical  intervention,  as  wre  exclude  the  gravest  cases 
from  operation.1 

Palliative  Surgical  Treatment. — A  number  of  surgical  means 
have  been  brought  forward  to  avoid  the  radical  operation  and 
have  been  successively  advised:  hemostatic  dilatation  of  the 
cervix,  intrauterine  curettage  and  cauterization,  atmocausis 
atrophying  ligatures,  ovarian  castration,  and  pressing  back  into 
the  abdomen  a  tumor  enclosed  in  the  pelvis,  and  producing 
compression  complications.  All  these  means  were  tried  when 
surgical  intervention  in  fibromas  was  a  serious  affair.  They  have 
no  reason  for  existence  to-day.  If  recourse  to  operation  is 

1  Kronig  et  Gauss,  Wie  weit  wird  durch  Rontgenbehandlung  unsere  operative 
Therapie  bei  Uterus  blutungen  und  Myomen  beeinflust?  Miinch.  med.  Woch.,  1910, 
p.  1529. 


432  TREATMENT   OF   NEOPLASMS   OF   THE   UTERUS 

imperative,  do  the  radical  operation,  which  is  hardly  more 
serious  than  operation  of  minimal  appearance,  and  in  addition 
it  is  a  curative  operation. 

II.  Radical  Treatment. 

As  uterine  fibroids  are  so  various  the  operations  are  also. 

For  polyps  which  project  into  the  vaginal  cavity,  vaginal 
polypectomy  is  the  operation  of  choice. 

If  the  fibroid  simply  projects  into  the  uterine  cavity,  we  should 
do  a  transvagino-uterine  myomectomy  after  first  doing  a  prelim- 
inary hysterotomy. 

In  all  these  cases  there  is  no  discussion  on  the  choice  of  pro- 
cedure. For  other  varieties  of  fibromas,  however,  opinions 
differ;  some  desire  the  conservative  intraperitoneal  myomectomy, 
while  others  of  the  radical  school  cannot  agree  and  either  do 
vaginal  hysterectomy  or  abdominal  hysterectomy. 

Abdominal  Myomectomy. — After  opening  of  the  abdomen,  if 
we  find  a  single  tumor  pediculated,  myomectomy  is  the  operation 
of  choice.  It  is  even  advised  to  do  this  in  single  tumors  which  are 
sessile,  but  projecting  markedly  from  the  external  surface  of  the 
uterus. 

If  it  is  necessary  to  have  recourse  to  it  for  interstitial  fibroids, 
and  above  all  for  multiple  fibroids,  Martin,  in  Germany,  Kelly, 
in  America,  and  Tuffier,  in  France,  advocate  this  operation.  It 
is  very  tempting  to  confine  the  operation  to  incision  of  the  cap- 
sule of  the  fibromas  and  to  their  enucleation ;  it  is  the  conservative 
treatment,  par  excellence.  The  patient  continues  her  men- 
struation and  may  have  children.  Of  109  operations  Temoin1 
has  observed  five  pregnancies  come  to  a  favorable  conclusion ;  Engs- 
strom  in  1 80  cases  had  nine  pregnancies.  But  these  are  particularly 
fortunate  results.  Winter2  collected  129  remote  cases  of  myomec- 
tomy, and  found  only  three  pregnancies  and  of  these  three  one 
ended  in  an  abortion  at  the  third  month.  Schauta  only  had  one 
single  pregnancy  in  39  cases.  Graf  in  30  myomectomies  only  had 

1  Cited  by  Tuffier  and  de  Rouville,  Report  to  the  XV.  Congres  international  de 
medecine,  Lisbonne,  1906. 

2  Winter,   Die  wissenschaftlichen    Geundlagen    f iir    conservativen  Myomoperation . 
Zeitschr.  f.  Geb.  u.  Gyn.,  Stuttgart,  1904,  T.  LI,  p.  105. 


TREATMENT  OF  UTERINE  FIBROMATA  433 

one  pregnancy  and  which  terminated  in  an  abortion  at  the  third 
month. l 

The  argument  thus  shown  of  the  possibility  of  consecutive 
pregnancies  while  it  still  has  a  certain  value,  has  less  than  one 
would  a  priori  suppose. 

On  the  other  hand,  while  the  mortality  has  diminished  since 
1890,  when  Martin  had  18  deaths  in  96  operations,  the  average 
mortality  of  abdominal  myomectomy  is  considerably  higher  than 
that  of  other  operations  for  myomas.  According  to  Winter, 
it  is  about  44  for  451  operations  or  9.8  per  cent.  It  is  true  that 
we  find  more  favorable  statistics,  as  Temoin  had  only  five  deaths 
in  109  operations  or  4.1  per  cent. 

~It  seems  to  us  that  as  practically  established  that  myomec- 
tomy which  is  only  applicable  to  fibroids  that  are  easily  removed 
having  no  adhesions,  and  without  lesions  of  the  adnexa  has  an 
incontestably  more  serious  prognosis  than  hysterectomy. 

If  we  add  that  many  women  complain  after  this  operation 
of  persistent  trouble,  of  inability  to  work,  and  seeing  that  one 
cannot  be  sure  of  removing  all  the  nodules,  also  that  sometimes 
we  have  recurrences  necessitating  a  second  operation,  it  will  be 
understood  that  its  indications  are  relatively  limited;  e.g.,  a 
young  woman  desirous  of  having  children,  and  having  only  one 
or  at  least  a  small  number  of  myomas  and  without  any  inflam- 
matory lesions  of  the  adnexa. 

Vaginal  Hysterectomy. — Vaginal  hysterectomy,  which  has 
been  applied  by  Segond  to  large  tumors  reaching  up  as  high 
as  the  umbilicus,  has  gradually  had  its  domain  restricted  by 
abdominal  hysterectomy.  Personally  we  have  hardly  ever  used 
it.  In  its  favor  its  lessened  gravity  has  been  advocated;  that  is 
wrong,  the  mortality  of  the  abdominal  operation  in  small  or 
medium-sized  fibroids  is  to-day  almost  nil.  That  which  raises 
the  mortality  of  the  abdominal  operation  is  that  the  operation 
is  the  only  one  applicable  to  the  enormous  tumors  often  accom- 
panied by  renal  lesions  or  cardiac  degeneration  tumors  which 
even  the  most  ardent  partisans  of  the  vaginal  route  are  forced 
to  remove  by  the  abdomen.  Even  burdened  with  these  bad 

1  Raoul  Graf,  Zur  Frage  der  konservativen    Myomoperationen.     Zeitschr.  f.  Geb.  u. 
Gyn.,  Stuttgart,  1906,  T.  LVI,  p.  103. 
28 


434  TREATMENT   OF   NEOPLASMS   OF   THE    UTERUS 

cases  it  is  certain  that  abdominal  hysterectomy  is  preferable  to 
vaginal. 

We  will  prove  this  by  taking  the  statistics  of  the  most  ardent 
advocates  of  vaginal  hysterectomy  in  France : 

Segond,  66  cases,  7  deaths. 

Bouilly,  109  cases,  8  deaths. 

Richelot,  139  cases,  5  deaths. 

Total,  314  cases,  20  deaths,  or  a  mortality  of  6.36  per  cent, 
and  our  abdominal  operations  give  a  mean  mortality  of  4.1  per 
cent.,  that  is,  11  deaths  in  268  cases. 

Vaginal  hysterectomy  is  still  indicated  for  medium-sized  or 
small  tumors,  situated  low  down  in  women  with  an  excess  of 
adipose  tissue  on  the  abdominal  wall  and  having  at  the  same 
time  a  large  vagina  and  a  dilated  or  easily  dilatable  vulva. 

Abdominal  Hysterectomy. — Abdominal  hysterectomy  is  indi- 
cated in  the  immense  majority  of  myomas.  The  only  question 
which  presents  itself  is,  if  it  is  better  to  have  recourse  to  a  total 
or  subtotal  operation.  One  of  the  arguments  in  favor  of  total 
is  the  possibility  of  a  cancer  developing  secondarily  in  the  cervix 
left  behind.  Botzony  has  gathered  together  27  cases;  it  is  fair 
to  add  that  after  total  hysterectomy  secondary  cancers  of  the 
vagina  have  already  been  published. 

Again,  total  hysterectomy  is  certainly  more  serious  than  sub- 
total; it  is  about  6.6.  per  cent,  in  499  cases  for  the  total  and  2.61 
per  cent,  in  724  cases  of  subtotal,  according  to  the  statistics  of 
Botzony.  The  subtotal  removal  we  consider  is  the  operation  of 
choice  and  we  only  do  the  total  in  those  cases  where  the  cervix 
is  chronically  inflamed.  In  a  general  way,  it  is  admitted  that 
the  preservation  of  one  or  both  ovaries  is  useful  as  preventing 
the  complications  of  the  artificially  induced  menopause. 

2.  Fibroids  and  Pregnancy. 

It  is  difficult  to  give  precisely  the  indications  for  treatment 
in  cases  of  myomas  complicating  pregnancy,  as  there  is  little 
agreement  on  the  subject  of  the  reciprocal  influence  of  myomas 
and  pregnancy. 

There  is  still  a  subject  of  discussion,  the  influence  of  myomas 
on  conception,  on  the  evolution  of  pregnancy  and  its  termination. 


FIBROIDS  AND  PREGNANCY  43o 

While  Hofmeier,  Pinard  and  others  do  not  regard  myomas 
as  being  a  cause  of  sterility,  Olshausen  finds  that  30  per  cent, 
of  women  with  fibroids  are  sterile,  and  Winckel  finds  41.6  per 
cent.  The  coincidence  of  fibroids  and  sterility  appears  undeni- 
able but  we  are  not  tempted  to  accept  Pinard's  opinion  that  a 
woman  has  a  myoma  because  the  uterus  has  not  fulfilled  its 
function  of  gestation. 

Opinions  differ  even  on  the  action  of  fibroids  on  the  evolution 
of  pregnancy.  Jamain,  in  his  thesis,  inspired  by  Pinard,  writes 
that  fibroids  in  the  great  majority  of  cases  do  not  hinder  pregnancy 
in  any  way.1 

And  while  Pinard  found  20  abortions  or  miscarriages  in  84 
pregnancies  in  fibromatous  uteri,  Anton  Garkisch  found  86 
abortions  in  232  pregnancies.2 

The  same  lack  of  agreement  from  the  point  of  view  of  pres- 
entation when  the  pregnancy  arrives  at  term. 

P.  C.  =^90  per  cent.  (Pinard) ;  54  (Olshausen) ;  51  (Lefour) ; 
P.  S.  =7.8  per  cent.  (Pinard) ;  24  (Olshausen) ;  32  (Lefour). 
P.  Tr.=0.9  per  cent.  (Pinard) ;  19  (Olshausen) ;  17  (Lefour) ; 

On  a  single  point  the  opinions  agree:  the  relative  frequency 
of  the  faulty  insertion  of  the  placenta. 

In  presence  of  the  divergences  of  opinion,  it  can  be  understood 
that  the  indications  of  operative  intervention  have  been  very 
variously  regarded.  It  appears  that  accord  tends  to  limit  the 
domain  of  the  operation  and  in  a  general  way  the  operation 
should  be  rejected. 

While  when  there  are  serious  complications,  such  as  hemor- 
rhage, torsion  of  the  pedicle,  etc.,  or  when  the  tumor  develops 
rapidly,  or  if  there  is  acute  pain,  the  surgeon  is  authorized  to 
intervene. 

If  it  is  possible  to  do  a  myomectomy  without  opening  the 
uterine  cavity,  it  would  be  done  in  the  hope  of  seeing  the  preg- 
nancy continue  its  evolution.  But,  if  the  myomas  are  big  and 
developed  in  the  inferior  segment  of  the  uterus  or  projecting 
into  the  uterine  cavity,  a  radical  operation  is  necessary.  If  the 

1  Jamain,  Uterine   Fibroids    and    Puerperality.     Th.  de  Paris,  G.    Steinheil,  1906- 
1907,  No.  37.     See  discussions  of  the  Society  d'obstetrique  de  gynecologic  et  de  p6dia- 
trie,  Paris,  1900,  and  of  the  American  Gynecological  Society  of  1903. 

2  Anton  Garkisch,  Klin,  und  anatom.  Beitr.  z.  Lehre  v.   Uterusmyom,  Berlin,  1910. 


436  TREATMENT   OF   NEOPLASMS   OF  THE   UTERUS 

fetus  has  not  reached  the  age  of  viability  we  should  have  recourse 
to  hysterectomy. 

If  the  fetus  is  viable,  the  operation  of  choice  appears  to  us 
to  be  Cesarean  section,  followed  immediately  by  hysterectomy. 

Leaving  out  complications,  should  one  in  all  cases  await 
labor  and  proceed  to  the  accouchement  per  vias  naturales?  In 
order  to  give  an  idea  of  that  which  this  line  of  conduct  leads  to 
we  have  Pinard's  statistics  published  by  Jamain  in  158  cases: 

In  158  women,  we  find  23  infants  dead  before,  or  during,  or 
immediately  after  confinement,  one  confinement  at  five  months, 
two  at  seven  months,  five  at  eight  months,  three  at  eight  and  one- 
half  months,  41  during  the  ninth  month  and  15  near  term;  68  only 
reached  full  term.  Fibroids  have  therefore  an  unfortunate  influ- 
ence on  the  normal  development  of  the  fetus;  it  would  be  still 
greater  if  only  the  really  grave  cases  were  taken  into  considera- 
tion, because  in  these  statistics  figure  a  large  number  of  cases 
where  there  was  only  a  medium-sized  or  small  fibroid,  developed 
in  the  body  of  the  uterus  and  not  appearing  to  interfere  with  the 
development  of  the  uterus  and  labor.  Also  we  believe  that  dis- 
tinctions should  be  made  between  cases.  For  the  non-encapsu- 
lated we  should  await  term  and  seek  to  obtain  expulsion  per  vias 
naturales;  in  the  presence  of  fibroids  developed  in  the  inferior 
segment,  above  all  in  cases  of  multiple  tumors,  we  do  not  hesitate 
to  operate  before  labor,  doing  first  a  Cesarean  section  followed 
by  hysterectomy.  In  the  hands  of  an  experienced  surgeon  the 
operation  seems  hardly  more  risky  than  the  total  of  immediate 
risks  and  those  resulting  from  a  secondary  removal  of  fibroids, 
and  the  chances  of  having  a  living  child  are  perhaps  greater. 

After  accouchement,  a  rapid  intervention  is  only  indicated  if 
there  are  complications  of  gangrene,  suppuration,  or  septicemia. 
With  the  exception  of  these  cases,  one  should  always  wait  until 
the  end  of  the  period  of  involution  of  the  uterus  before  making 
a  decision,  reflecting  well  on  the  operative  indications  as  in  ordi- 
nary cases  quite  apart  from  any  modification  due  to  pregnancy. 

3.  Malignant  Tumors  of  the  Uterus. 

The  recognized  existence  of  a  sarcoma  of  the  uterus  constitutes 
an  indication  of  immediate  total  removal  of  the  organ.  This 


MALIGNANT  TUMORS  OF  THE  UTERUS  437 

operation  should  give  real  cures.  Gessner  in  his  statistics  of 
61  cases  gives  the  following  results: 

Twenty-six  sarcomas  of  the  mucous  membrane,  ten  recur- 
rences, five  at  the  end  of  two,  three,  five,  six  and  seven  months, 
four  after  one  year,  one  after  two  years;  16  have  been  under 
observation  and  are  well,  four  after  one  to  two  years,  five  after 
two  to  three  years,  one  after  three  years,  one  after  five  years, 
two  after  six  years,  three  after  four  years,  one  after  five  years, 
two  after  seven  years  and  two  after  eleven  years. 

Thirty-five  sarcomas  of  the  wall,  14  recurrences  between  one 
month  and  four  years,  21  patients  have  been  seen  again  without 
recurrence;  11  after  two  years,  two  after  three  years,  three  after 
four  years,  one  after  five  years,  two  after  seven  years  and  two 
after  nine  years. 

The  radical  operation  of  cancer  of  the  uterus  gives  even  more 
lengthy  cures,  as  we  have  already  mentioned  in  dealing  with 
abdominal  colpohysterectomy. 

We  may  therefore  conclude  that  the  treatment  of  malignant 
tumors  of  the  uterus  is  essentially  operative  and  that  if  a  total 
removal  of  invaded  parts  could  be  carried  out  it  should  always 
be  done.  We  will  not  return  to  the  indications  of  the  so-called 

v 

radical  operation  as  we  have  gone  into  them  very  thoroughly 
under  the  heading  of  abdominal  hysterectomy  and  we  will  deal 
only  here  with  cases  that  justify  a  palliatve  treatment. 

Some  gynecologists1  advised  vaginal  hysterectomy  for  cancers 
which  having  gone  beyond  the  limit  of  indications  for  the  radical 
operation  are  not  nevertheless  too  advanced  (D.  de  Ott,  Bouilly). 
The  removal  of  the  uterus  would  suppress  hemorrhages  and  dis- 
charges ;  the  recurrence  taking  place  above  the  dome  of  the  vagina 
would  result  in  a  long  interval  of  time  elapsing  before  ulceration 
occurred.  Formerly  we  followed  this  practice;  the  results  we 
obtained  did  not  appear  to  us  to  be  superior  to  those  of  simple 
curettage.  We  have  also  rapidly  abandoned  this  operation, 
which  gives  an  early  and  serious  prognosis. 

The  best  of  palliatives  is  curettage,  which  is  followed  by  igneous 
cauterization.  It  is  the  treatment  "par  excellence"  for  hemor- 
rhages and  ichorous  discharges,  which  are  so  annoying  to  the 
patient.  Curettage  is  also  done  as  completely  as  possible  and 

1  See  J.  R6camier,  Treatment  of  Inoperable  Cancer.     Paris,  G.  Steinheil,  1905. 


438  TREATMENT   OF   NEOPLASMS   OF   THE    UTERUS 

followed  by  an  energetic  cauterization  with  the  thermocautery. 
This  is  successively  passed  over  the  whole  extent  of  the  cavity; 
the  floating  debris  of  the  cervix  are  excised  and  the  cavity  made 
smooth.  Finally  we  finish  the  operation  by  making  an  extensive 
lavage  with  sublimate  solution,  drying  the  part  and  tamponing 
with  simple  or  iodoform  gauze. 

The  results  are  excellent  and  the  mortality  nil.  It  is  astonish- 
ing to  see  how  the  parts  heal  and  curettage  may  in  certain  cases 
be  repeated  several  times  with  advantage  during  the  course  of 
the  disease. 

Its  use  is  well  established  in  cancer  with  consecutive  pyometra 
following,  combined  oftenest  with  cancers  of  the  isthmus,  where 
the  intrauterine  secretions  do  not  discharge  well  on  account  of 
the  blocking  up  of  the  inferior  portion  due  to  the  intracervical 
tumor  which  obliterates  the  canal  of  the  cervix.  This  compli- 
cation only  disappears  when  a  large  opening  permits  of  regular 
evacuation  and  lavage  of  the  uterine  cavity.  Fever  and  expulsive- 
like  pains,  intermittent  discharges  of  pus,  and  sometimes  of  gas 
cease  when  a  tunnel  has  been  made  bringing  freely  into  communi- 
cation the  interior  of  the  uterus  and  the  vagina. 

Chemical  cauterization  with  chloride  of  zinc,  carbide  of 
calcium,  etc.,  appear  to  us  to  be  inferior  to  curettage;  their 
application  is  often  very  painful  and  it  is  impossible  to  limit 
their  action. 

For  nodular  epitheliomas  of  the  cervix  quite  inoperable  and 
with  bleeding  cancerous  vegetation  sometimes  non-ulcerated, 
methylene  blue,  2  to  1000  (Mosetig-Moorhoff)  has  been  recom- 
mended. It  is  given  as  an  injection.  Absolute  alcohol  injec- 
tions (Schultz)  are  also  recommended.  These  injections  appear 
to  act  by  bringing  about  a  necrosis  of  certain  points  of  the 
tumor  and  in  bringing  about  a  formation  of  fibrous  tissue  at  its 
periphery,  which  retards  the  growth  of  the  neoplasm.  We  have 
no  experience  of  these  forms  of  treatment,  as  we  always  prefer 
conoidal  amputation  of  the  cervix  with  a  thermocautery. 

Atrophying  ligatures  with  which  wre  have  experimented  have 
only  given  a  very  temporary  arrest  of  the  secretions  and  we 
cannot  recommend  them.  The  application  of  X-rays  and  above 
all  radium  therapy  often  bring  about  a  superficial  cicatrix,  but 


MALIGNANT  TUMORS    OF  THE  UTERUS  439 

below  the  lesions  progress  and  the  very  small  amelioration  is  in 
short  less  than  that  which  follows  curettage. 

With  the  exception  of  curettage,  followed  by  igneous  cauteri- 
zations, we  can  only  recommend  as  local  treatment  the  em- 
ployment of  antiseptic  injections  (potass,  permang.,  hydrogen 
peroxide,  and  Labarraque's  liqueur)  and  vaginal  dressings. 
The  latter  are  particularly  useful  if  we  have  to  deal  with  repeated 
hemorrhages;  simple  iodoform  tampons  suffice  to  stop  them. 

If  the  neoplasm  has  invaded  the  rectum,  if  a  large  fistula 
exists  with  an  incessant  discharge  of  matter  from  the  vagina  or 
if  the  cancerous  vegetations  in  the  intestine  interfere  with  its 
evacuation  we  may  relieve  the  patient  by  doing  an  iliac  colos- 
torfiy.  Pauchet  did  successfully  a  bilateral  shutting  off  of  the 
intestine  in  a  woman  whose  ileum  had  a  fistula  at  a  point  where 
a  recurrence  had  occurred  secondary  to  a  vaginal  hysterectomy. 
In  all  these  cases  of  secondary  invasion  of  the  intestine  it  is  the 
intestinal  lesion  wrhich  demands  intervention,  and  treatment 
should  be  carried  out  as  if  no  uterine  cancer  existed. 

When  the  bladder  is  invaded  and  a  vesico-vaginal  fistula  is 
formed  the  continuous  discharge  of  urine  leads  rapidly  to  very 
painful  erythema,  and  if  one  is  not  careful  to  a  slough  of  the 
sacrum.  There  is  no  operative  treatment  to  advocate ;  it  is  better 
to  make  the  patient  lie  on  a  rubber  mattress  which  is  perforated 
and  to  wash  out  the  vagina  repeatedly  with  a  solution  of  bicar- 
bonate of  soda  in  1  to  1000  or  1  to  5000  so  as  to  diminish  the 
irritation  caused  by  the  passage  of  urine  and  to  pacify  the  pain- 
ful erythema.  The  free  application  of  25  per  cent,  zinc  oxide 
ointment  to  the  skin  in  order  to  protect  it  is  of  service  and 
cystitis  and  sloughs  are  treated  in  the  usual  way. 

Toward  the  end  the  treatment  will  be  limited  to  supporting 
the  patient's  strength,  easing  her  pain  and  sometimes  to  inter- 
vene for  anuria  which  follows  on  compression  of  the  ureters. 
Section  of  the  posterior  nerve  roots  has  also  been  advised  to  quell 
intolerable  pain.  This  is  carried  out  at  the  level  of  the  lumbar 
enlargement  so  as  to  anesthetize  the  lower  limbs,  buttocks  and 
pelvis  (J.  L.  Faure),  separation  of  the  rectum  with  section  of  the 
presacral  sympathetic  branches  (Jaboulay),  distention  of  the  fila- 
ments of  this  sacral  plexus  by  injection  of  artificial  serum  between 
the  posterior  surface  of  the  rectum  and  the  anterior  surface  of 


440  TREATMENT   OF   NEOPLASMS   OF  THE   UTERUS 

the  sacrum,  and  finally  ano-rectal  dilatation  which  acts  indirectly 
on  the  uterine  pain  (Poncet). 

To  this  operative  treatment  of  pain  we  prefer  the  simple  use 
of  narcotics,  in  particular  subcutaneous  injections  of  morphin  or 
of  heroin,  wrhich  we  must  not  hesitate  to  give  in  sufficient  doses  to 
produce  sleep.  Suppositories  of  extract  of  thebaine  and  anti- 
pyrin  cachets  also  render  service.  Epidural  injections,  the  tech- 
nic  of  which  is  much  more  complicated,  do  not  appear  superior 
from  the  point  of  view  of  results. 

The  slow  uremia  characterized  by  oliguria,  gastric  troubles, 
changes  in  the  temperament  improve  after  giving  saline  purga- 
tives, oily  enemas,  subcutaneous  injections  of  artificial  serum, 
caffeine,  pilocarpine  and  milk  diet. 

To  combat  early  anuria  due  to  compression  of  the  ureters, 
various  operations  have  been  done  such  as  lumbar  uretero- 
neostomy  (Le  Dentu),  nephrostomy  (Legeu,  Chavannaz, 
Poncet,  Jayle).  It  must  be  understood  that  this  anuria  is  often 
remittent  and  that  after  several  days,  under  the  influence  of  diu- 
retics and  injections  of  serum,  the  secretion  has  reappeared  and 
the  state  of  the  patient  improved.  We  hardly  ever  advise  these 
operations,  W7hich  are  often  useless  and  which  in  case  of  success 
only  lead  to  a  prolongation  of  a  miserable  life. 

4.  Uterine  Cancer  and  Pregnancy. 

In  presence  of  a  uterine  cancer  complicated  by  pregnancy1  the 
therapeutic  indications  are  governed  by  the  degree  of  operability 
of  the  mother  and  the  state  of  viability  of  the  fetus. 

The  first  question  that  appears  is:  Is  the  cancer  operable  or 
non-operable  ? 

Operable  Cancer. — The  evolution  of  cancer,  during  pregnancy, 
is  extremely  rapid  and  we  should  not  hesitate  about  a  decision; 
it  would  result  probably  in  sacrificing  the  life  of  the  mother,  while 
conserving  limited  chances  of  saving  the  infant. 

During  the  first  four  months  the  operation  is  that  of  vaginal 
hysterectomy.  The  uterus  is  drawn  down  to  the  vulva  very 
easily  because  of  the  relaxation  of  its  suspensory  apparatus 

1  Cullen,  Cancer  of  the  Uterus,  N.  Y.,  1900.     Oui,  Ann.  de  gyn.,  Paris,  1907,  p.  193. 
Sarvey,  Handb.  d.  Gyn.  de  Veil,  Wiesbaden,  1899,  T.  Ill,  second  part,  p.  489. 


UTERINE  CANCER  AND  PREGNANCY  441 

following  on  pregnancy.  The  uterus,  generally,  may  be  taken 
out  en  bloc  with  its  contents.  At  the  fifth  or  seventh  month  total 
abdominal  hysterectomy  has  been  done,  supravaginal  amputation 
being  followed  by  extirpation  of  the  cervix  by  the  vagina  (Zweifel), 
and  the  abortion  having  been  excited  is  followed  by  vaginal  hys- 
terectomy once  the  involution  is  effected.  To-day  the  general 
tendency  is  in  this  case,  to  do  a  vaginal  hysterectomy,  splitting 
the  uterus  once  the  cervix  is  liberated  from  the  vagina  and  the 
parametrium,  and  afterward  proceeding  to  the  extraction  of  the 
fetus  and  finishing  as  usual.  It  is  about  the  eighth  month  that 
the  question  of  the  child  occurs.  We  must  bring  forth  a  living 
child  and  do  a  radical  operation  for  the  mother.  We  do  then  a 
Cesarean  operation  followed  by  a  total  hysterectomy  in  the 
usual  way. 

At  the  time  of  accouchement  we  cannot  hope  for  a  sufficient 
dilatation  of  the  cervix  if  the  cancer  is  limited  as  the  invaded 
parts  are  incapable  of  extension. 

If,  on  the  contrary,  the  cancer  is  extensive  we  may  do  a 
Cesarean  section  and  then  hysterectomy. 

Immediately  after  the  accouchement  and  without  awaiting  the 
involution  of  the  uterus  we  do  a  vaginal  hysterectomy,  the  dila- 
tation of  the  vagina  renders  the  operation  very  easy  and  the 
uterus  may  be  drawn  down  as  far  as  one  likes. 

In  spite  of  the  rapidity  of  evolution  of  the  cancer  in  the 
gravid  uterus,  these  operations  have  shown  some  survivals. 
Olshausen,  who  did  25  vaginal  hysterectomies  with  25  successes, 
had  up  to  the  time  of  publication  of  his  article,  followed  nine 
patients  during  a  fairly  long  interval  and  of  these  one  died  after 
six  months ;  four  of  them  had  recurrences  after  five,  six  and  one- 
half,  seven  months  and  three  and  one-half  years,  respectively; 
four  wrere  well  after  two  and  one-half  years,  five  and  three- 
fourths  years,  six  and  one-half  years,  and  seven  and  one-half 
years  respectively. 

Inoperable  Cancer. — If  the  cancer  is  inoperable,  the  child  is 
the  first  consideration.  We  confine  ourselves  to  a  symptomatic 
treatment.  If  the  mother  dies  and  the  child  is  viable,  we  may 
do  an  immediate  Cesarean  section.  At  term,  as  soon  as  labor  has 
commenced,  do  a  curettage  of  the  cancerous  vegetations,  make 
a  star-shaped  incision  in  the  cervix  and  extract  the  child  either 


442  TREATMENT   OF   NEOPLASMS   OF   THE    UTERUS 

with  forceps  or  by  version.  The  fetal  mortality  is  seven  deaths 
in  29  cases  or  about  25  per  cent.  In  reality  it  is  considerably 
higher,  since  to  these  29  cases  we  should  in  reality  add  10  in 
which  perforation  was  carried  out,  so  that  we  see  that  extraction 
per  vias  naturales  gives  in  reality  a  mortality  of  43.57  per  cent. 
It  appears  preferable  to  do  Cesarean  section,  which  is  followed 
by  Porro's  operation,  being  careful  not  to  cut  the  uterus  too  near 
the  cancer,  because  of  the  inflammatory  infiltration  of  uterine 
tissue  which  exists  in  its  neighborhood.  This  procedure  is  less 
grave  than  the  conservative  Cesarean  operation,  which  in  cases 
of  cancer  is  often  followed  by  septic  complications.  The  fetal 
mortality  is  considerable,  about  27  per  cent. ;  it  is,  however,  less 
than  that  of  extraction  per  vias  naturales;  the  results  would  be 
still  better  if  the  operation  had  not  been  often  practiced  too 
late,  when  the  child  had  already  succumbed  during  the  course 
of  a  prolonged  labor  (Oui). 

5.  Tumors  of  the  Ovary. 

During  the  opening  period  of  abdominal  surgery  operations 
were  limited  to  the  removal  of  cysts  of  the  ovary  when  by  their 
large  size  they  seemed  likely  to  injure  the  general  health.  In 
1883  Spencer  Wells  declared  that  it  would  be  better  to  remove 
ovarian  tumors  as  soon  as  they  were  diagnosed.  To-day  the  rule 
is  fixed:  every  ovarian  tumor  when  diagnosed  should  be  removed 
immediately. 

The  operation  when  done  at  the  commencement  is  less  grave 
and  places  the  patient  in  a  position  of  acquiring  numerous  com- 
plications such  as  inflammation  and  rupture  of  the  cyst  and 
torsion  of  its  pedicle.  Finally  malignant  degeneration  may 
occur,  as  in  658  cases  of  cysts  removed  by  Schroder,  100  were 
degenerated. 

Malignancy  of  tumors  does  not  constitute  contraindication  to 
intervention. 

While  speaking  of  this,  we  should  make  special  mention  of 
papillary  cysts,  the  removal  of  which  when  they  are  accom- 
panied by  ascites  and  peritoneal  grafts,  may  be  followed  by  a 
recurrence  so  late,  5,10  and  20  years  after,  as  almost  to  constitute 
a  cure  (Pozzi).1 

1  Pozzi,  Rev.  de  gyn.  et  de  Chir.  abd.,  Paris,  1904,  p.  407. 


TUMORS  OF  THE  OVARY  AND  PREGNANCY         443 

Age  is  no  contraindication ;  cures  have  been  brought  about  in 
infants  of  one  year  and  old  people  past  80. 

The  only  question  discussed  is  that  of  knowing  if  in  the  case 
of  finding  a  unilateral  ovarian  tumor,  one  should  remove  the 
ovary  of  the  opposite  side.1  This  opinion  is  supported  by  a 
certain  number  of  gynecologists.  Personally  we  remove  the 
healthy  ovary  whenever  this  organ  has  ceased  its  functions;  on 
the  contrary,  in  young  women  we  always  keep  the  healthy  organs, 
these  that  in  a  certain  number  of  cases  we  have  seen  pregnancies 
develop  to  the  great  joy  of  our  former  operated  patients. 

6.  Tumors  of  the  Ovary  and  Pregnancy. 

Audebert  has  collected  241  ovariotomies  done  during  preg- 
nancy and  finds  five  deaths  or  2.1  per  cent;  in  79  per  cent,  of 
cases  the  pregnancy  went  on  to  full  development.2  It  is  clearly 
seen  that  any  ovarian  tumor  diagnosed  during  pregnancy  should 
be  operated  on.  Is  there  any  object  in  waiting  until  the  sixth  or 
seventh  month  so  as  to  increase  the  chances  of  viability  of  the 
fetus  ?  We  do  not  agree  with  this  and  think  with  Pozzi  that  all 
a  tardy  intervention  causes  is  a  new  risk  to  both  mother  and 
infant.  The  indication  is  to  operate  as  soon  as  the  diagnosis 
is  made. 

We  take  certain  precautions  during  the  course  of  the  interven- 
tion. We  make  an  incision  long  enough  to  easily  extract  the  cyst, 
the  volume  of  which  has  been  already  reduced  by  puncture,  gently 
draw  the  tumor  outward  and  avoid  traction  on  its  pedicle.  After 
the  operation,  as  Pinard  does,  we  give  systematic  injections 
of  morphia  in  order  to  prevent  the  production  of  uterine  con- 
tractions. 

During  labor  we  should  only  intervene  if  the  tumor  by  reason 
of  its  pelvic  site  prevents  the  engaging  and  expulsion  of  the  fetus. 
We  should  try  to  press  it  back  with  our  fingers  which  are  intro- 
duced into  the  rectum,  avoiding  the  while  too  violent  pres- 
sure which  may  rupture  a  cystic  loculus.  In  case  of  failure 
open  the  abdomen  and  remove  the  tumor,  and  if  this  is  im- 
possible do  Cesarean  section. 

1  D.  v.  Velitz,  Ueber  die  Dauererfolge  der  Ovariotomie,  Arch,  fur  Gyn.,  Berlin,  1906, 
T.  LXXIX,  p.  533. 

2  Audebert,  Soc.  d'obsl.,  gyn.  et  ped  ,  Paris,  Oct.  10,   1904. 


CHAPTER  III. 

DISPLACEMENT  OF  THE  UTERUS. 

Summary. — Treatment  of  genital  prolapse. — Means  of  fixation  of  the 
uterus. — Anatomo-pathological  lesions  of  prolapse. — Prophylactic  treatment; 
medical  treatment  (massage,  pessaries,  injections  of  paraffin  and  quinine). 
— Operative  treatment. — Treatment  of  vaginal  enterocele. — Treatment  of 
uterine  deviations  (exaggerated  mobility,  anteflexion,  retrodeviation,  retro- 
flexion  of  the  gravid  uterus). — Uterine  inversion  (puerperal  and  polypoid). 

In  this  chapter  we  will  successively  study  the  treatment  of 
prolapse  and  that  of  deviations. 

1.  Treatment  of  Genital  Prolapse. 

Before  beginning  the  study  of  the  therapeutics  of  genital 
prolapse  it  appears  to  us  to  be  of  advantage  to  recall  in  two 
words  the  disposition  of  the  means  of  fixation  of  the  uterus  and 
vagina.  This  short  anatomical  glance  will  enable  us  to  better 
grasp  the  pathogeny  of  prolapse  and  of  exposing  in  a  rational 
manner  the  indications  of  their  treatment. 

The  pelvic  organs  in  a  woman  are  maintained  in  their  normal 
position  by  various  agents,  those  of  suspension  and  others  of 
support. 

Principal  among  the  suspension  agents  we  find  the  peritoneal 
folds  which  run  from  the  uterus  to  the  walls  of  the  pelvic  cavity, 
broad  ligaments,  round  ligaments,  and  utero-sacral  ligaments. 
If  these  ligaments  were  only  formed  of  peritoneal  folds  they 
would  count  for  very  little.  Reinforced  as  they  are  by  fibrous 
or  muscular  tissue  derived  from  the  uterus  (round  ligaments, 
utero-sacral  ligaments,  and  ligaments  which  run  from  the  border 
of  the  uterine  cervix  to  the  pubis,  taking  their  course  external  to 
the  vesico-pubic  ligaments  which  they  reinforce),  they  constitute 
but  feeble  means  of  fixation  and  are  practically  only  small  cords 
of  moderate  tension.  Below  is  the  sheath  of  the  uterine  artery 
and  the  sacro-recto-genital  aponeurosis.  It  is  agreed  to-day,  as 

444 


TREATMENT  OF  GENITAL  PROLAPSE 


445 


Farabeuf  stated,  that  both  are  only  appendages  of  a  perivascular 
fibrous  formation  which  is  very  unequal  in  its  development,  and 
included  with  the  intra-pelvic  branches  of  the  internal  iliac  is 
called  the  hypogastric  sheath.  Its  role  is  more  manifestly  seen 
along  the  borders  of  the  vagina,  where  it  is  a  resistant  sheath 
accompanying  the  vessels  and  constituting  the  most  efficacious 
means  of  fixation  of  this  canal. 


FIG.  360. — Means  of  suspension  of  and  ligaments  of  the  uterus  (after  Farabeuf.) 

The  means  of  support  are  disposed  about  several  planes 
arising  from  the  perineum. 

We  first  notice  the  perineal  body,  which  is  constituted  essen- 
tially by  the  anterior  segment  of  the  anal  sphincter,  the 
transversalis  superficialis  and  the  constrictor  of  the  vulva. 

Immediately  below  is  a  sort  of  diaphragm,  partly  fibrous  and 
partly  muscular,  which  springs  from  the  pubic  arch  behind  the 
ischio-cavernous  muscles  and  is  inserted  into  the  vagina  behind 


446  DISPLACEMENT   OF   THE   UTERUS 

and  laterally  into  a  point  corresponding  to  the  hymen.  Ante- 
riorly this  diaphragm  is  less  well  developed  and  is  easily  per- 
forated by  the  finger  on  the  line  with  the  urethra. 

Deeper  anteriorly  we  find  the  pubo-vesical  ligaments  coming 
off  from  the  internal  face  of  the  pubis,  laterally  and  posteriorly 
the  fibers  of  the  levators  which  gird  the  vagina  laterally  and 
proceed  toward  the  preanal  fold,  then  to  the  sides  of  the  anus 
and  then  behind  the  anus,  thus  constituting  an  infundibuliform 
diaphragm  on  which  the  pelvic  viscera  lie. 

These  various  means  of  fixation  have  an  unequal  importance 
and  the  section  of  the  means  of  suspension  facilitates  much  less 
the  descent  of  the  uterus  than  vulvo-vaginal  splitting.  The 
facility,  however,  with  which  one  draws  the  cervix  to  the  vulva 
after  this  operation  is  a  current  observation  of  all  gynecologists. 

One  is  forced  to  admit  that  in  genital  prolapse  the  primordial 
lesion  is  represented  by  the  insufficiency  of  the  perineum.  In  fact, 
this  perineal  insufficiency  is  never  at  fault  without  being  in  direct 
relation  wTith  a  tear  of  the  perineum.  Torn  perineums  are  seen 
quite  often,  where  the  tear  extends  to  the  anus  without  the  least 
descent  of  the  genital  organs.  The  tear  favors  prolapse  but  does 
not  produce  it ;  it  is  necessary  at  the  same  time  that  there  exist  an 
insufficiency  of  the  supporting  power  of  the  levators  and  general 
degeneration  of  the  fibrous  tissues  of  the  pelvis. 

In  practice  several  cases  may  present  themselves.  Sometimes 
there  exists  an  evident  tear  dating  back  to  a  more  or  less  recent 
confinement  and  involving  the  perineal  body  to  a  greater  or  Jess 
extent.  Sometimes  insufficiency  is  of  obstetrical  origin,  but  the 
perineal  region  is  intact  in  appearance.  The  muscular  appa- 
ratus is  none  the  less  gravely  damaged;  it  is  a  question  in  these 
cases  of  subcutaneous  tears  of  the  muscles  and  the  palpation  of 
the  perineum  shows  it  to  be  relaxed,  thinned  and  reduced  to  a 
plane  of  integument.  This  atrophy  of  the  muscles  of  the  peri- 
neum is  independent  of  all  traumatism ;  we  have  to  deal  with 
patients  whose  muscular  system  is  degenerated  and  whose 
abdominal  wall  is  enfeebled  and  who  besides  their  genital 
prolapse,  suffer  from  ptoses,  renal  and  intestinal,  and  hernias,  etc. 

Whatever  else  may  be  the  cause  the  insufficiency  of  the 
perineum  opens  the  door  to  prolapse.  The  vagina  shows  a 
progressive  eversion  through  the  gaping  vulva.  Generally  there 


TREATMENT  OF  GENITAL  PROLAPSE 


447 


is  at  first  prolapse  of  the  anterior  vaginal  wall,  an  anterior 
colpocele,  then  of  the  posterior  vaginal  wall,  posterior  colpocele. 
Anterior  colpocele  is  always  accompanied  by  cystocele,  by  reason 
of  the  anatomical  solidarity  of  the  vesical  and  vaginal  walls. 
On  the  contrary,  the  posterior  colpocele  generally  exists  without 
an  accompanying  rectocele.  The  vagina  in  unfolding  becomes 
larger  and  assumes  manifestly  exaggerated  dimensions.  At  the 


FIG.  361. — Means  of  support  of  the  uterus.  Below  the  middle  aponeurosis  are 
the  muscles  which  by  their  convergence  go  to  form  the  perineal  body;  posteriorly 
the  fibers  of  the  levator  are  seen  to  emerge  from  its  posterior  face. 

same  time  the  uterus  becomes  progressively  lower  and  appears 
at  the  vulva  and  in  extreme  cases  may  issue  in  its  entirety  exter- 
nally, dragging  with  it  the  vagina.  It  goes  without  saying  that 
such  an  extreme  relaxation  of  all  the  ligaments  enters  into  these 
cases. 

The  falling  down  of  the  uterus  does  not  form  the  only  lesion 
of  this  organ.  Excepting  metritis  and  particularly  cervical 
metritis,  which  is  rarely  absent,  there  exists  a  much  more  char- 
acteristic lesion:  hypertrophy  of  the  cervix,  especially  of  the 
supravaginal  portion,  which  was  described  by  Huguier  a  long 


448  DISPLACEMENT   OF   THE   UTERUS 

time  ago,  but  which  he  was  wrong  in  attributing  as  the  primary 
cause  of  prolapse. 

The  more  the  uterus  falls  down  the  more  it  is  tilted  down  and 
backward,  by  reason  of  the  cervix  being  draw?n  anteriorly  and 
inferiorly  under  the  traction  of  the  anterior  vaginal  wall. 

Latterly,  Marion  and  his  pupil  Rousseaux  have  insisted  on 
the  importance  of  the  abdominal  depth,  primary,  congenital  or 
secondary  to  a  prolapse  of  the  uterus  or  of  the  pouch  of  Douglas.1 

As  may  be  seen,  the  lesions  of  prolapse  are  multiple  and  are 
most  often  combined ;  it  is  illogical  to  disassociate  them  from  the 
therapeutic  aspect  even  when  they  appear  to  be  differentiated. 
This  isolation  is  only  apparent  and  a  clinical  examination  will 
always  show  the  complexity  of  the  lesions. 

These  few  pathogenic  ideas  permit  us  to  approach  the  study 
of  the  different  modes  of  treatment  proposed  for  genital  prolapse.2 

Prophylactic  and  Medical  Treatment. 

Prophylactic  treatment  does  not  appear  to  have  a  great  impor- 
tance. It  has  been  pointed  out  how  important  it  is  to  repair 
perineal  tears  and  to  favor  uterine  involution,  so  that  the  parts  re- 
assume  their  volume  and  tonicity.  It  is  well  to  recommend  to 
young  women  after  labor  to  remain  in  bed  three  weeks  so  as  to 
avoid  premature  fatigue,  household  efforts  and  to  wear  an  abdom- 
inal belt.  But  we  repeat  we  must  not  have  any  illusions  about 
these  prophylactic  means. 

Medical  treatment  relieves  in  a  certain  degree,  but  does  not 
cure.  It  is  evident  that  in  cases  of  prolapse  which  have  remained 
a  long  time  exposed,  and  become  ulcerated,  methodical  reduc- 
tion, commencing  with  the  parts  nearest  the  vulva,  following  by 
antiseptic  dressings,  renders  great  service. 

It  is  a  necessary  treatment  before  commencing  operative 
intervention. 

The  genu-pectoral  position,  the  columning  of  the  vagina, 
and  the  use  of  astringent  injections  have  been  advocated.  Their 
efficaciousness  is  doubtful. 

1  Rousseaux,  Treatment  of  Certain  Cases  of  Uterine  Prolapse  by  the  Obliteration  of 
the  pouch  of  Douglas.     Th.  de  Paris,  1908-1909,  No.  7. 

2  We  will  leave  on  one  side  the  treatment  of  prolapse  symptomatic  of  a  tumor  of 
the   uterus  and   its  adnexa;   the   prolapse,    being  only  a   secondary  lesion,  is   cured 
on  removal  of   the  primary  cause.     (Ch.  de  Pierrepont,  Les  prolapsus  genitaux  symp- 
tomatiques.     Th.  de  Paris,  1903-04,  No.  511.) 


PROPHYLACTIC  AND  MEDICAL  TREATMENT  449 

Massage,  consisting  principally  in  movements  of  elevation 
of  the  uterus,  combined  with  Swedish  gymnastics,  have  given 
success. 

Pessaries  may  for  a  time  relieve  the  patient,  but  they  do 
not  hinder  the  progress  of  the  disease;  their  size  continually 
augments  and  finally  the  pessary  cannot  be  borne  any  longer, 
which  condition  is  produced  by  ulcerations  or  pains  or  what  is 
most  frequent,  it  will  no  longer  remain  in  place  and  becomes 
useless.  The  pessary  is  in  truth  only  useful  where  there  is  a 
resistant  floor.  In  other  cases  the  simple  pessary  is  insufficient 
and  if  for  special  reasons,  one  is  induced  to  have  recourse  to 
this  instrument  of  contention,  use  pessaries  with  a  stem  which 
protrudes  between  the  legs  and  is  supported  by  a  sort  of  T-bari- 
dage  (hysterophore) . 

We  should  also  mention  as  intermediate  in  the  medical 
treatment  and  the  operations,  the  injections  of  paraffin  the 
whole  length  of  the  vaginal  walls,  much  praised  by  Pankow, 
Douglas  and  W.  Stone,1  and  the  injections  of  quinine  as  Inglis 
Parsons2  does.  He  injects  into  the  base  of  the  broad  ligaments 
in  the  hope  of  provoking  a  curative  sclerosis  of  the  parametrium. 

In  short,  we  cannot  count  much  on  medical  treatment.  It 
is  important  to  leave  it  on  one  side  in  the  immense  majority  of 
cases.  It  may  be  employed  when  the  patient  formally  refuses 
intervention  and  for  any  reason  whatever  when  the  operation 
is  contraindicated.  We  would  then  have  recourse  to  pessaries  or 
hysterophores  if  the  pessaries  are  found  to  be  insufficient. 

Operative  Treatment. 

Operative  treatment  should  always  be  preceded  by  a  careful 
examination  of  the  patient;  this  will  enable  him  to  immediately 
distinguish  a  vaginal  hernia  from  prolapse  which  may  have  a 
pedicle  or  not  and  has  special  operative  indications. 

The  operations  for  genital  prolapse  are  very  numerous. 

Some  are  done  by  the  abdomen  and  their  object  is  to  render 
firmer  the  suspensory  ligaments,  etc.,  of  the  various  parts  con- 
stituting the  prolapse.  Some  surgeons  devote  their  attention  to 

1  Douglas  and  Stone,  Brit.  Med.  Journal,  1903,  T.  II,  p.  79. 

2  Inglis  Parsons,  Congres  intern,  des  sc.  medic.,  Paris,  1900. 

29 


450  DISPLACEMENT   OF  THE   UTERUS 

the  bladder,  the  displacement  of  which  is  generally  very  marked  in 
genital  prolapse,  and  have  carried  out  cystopexy.  Others  fix  the 
vagina  above.  The  majority  seek  to  act  on  the  uterus  either  by 
drawing  on  it  indirectly  by  the  shortened  round  ligaments 
already  done  in  the  inguinal  operation,  or  by  shortening  the 
utero-sacral  ligaments,  by  directly  fixing  them  to  tKe  anterior 
abdominal  wall  according  to  any  one  of  the  procedures  of 
hysteropexy.  Some  have  gone  further:  they  have  commenced 
by  a  hysterectomy  and  then  fixed  the  stump  either  to  the  anterior 
abdominal  \vall  or  to  the  stumps  of  the  broad  ligaments  (Jacobs, 
Ligamentary  trachelopexy). 

In  another  series  of  cases  gynecologists  have  operated  exclu- 
sively from  below,  confining  themselves  to  supporting  the  uterus 
by  constricting  the  vagina.  This  is  done  by  putting  in  a  series  of 
metallic  rings  under  the  mucous  membrane  or  by  making  a 
more  or  less  thick  belt,  by  doing  an  episorraphy,  a  partitioning  of 
the  vagina,  or  even  a  total  colpectomy  without  removal  of  the 
uterus. 

The  remote  results  of  these  various  operations  have  in  general 
been  mediocre.  As  we  have  seen  the  lesions  of  genital  prolapse 
are  multiple  and  the  treatment  should  therefore  be  complex. 

First,  we  must  diminish  the  hypertrophy  (cervix  and  vagina) ; 
second,  reconstitute  the  insufficient  perineal  support,  not  for- 
getting the  important  role  of  the  muscular  floor  formed  by  the 
levators;  third,  to  redress  the  retrodeviated  uterus. 

These  various  indications  are  carried  out  as  follows: 

An  amputation  of  the  cervix,  a  resection,  more  or  less  exten- 
sive, of  the  vaginal  walls  will  reduce  the  hypertrophied  parts; 
then  the  perineum  is  reconstituted  by  any  of  the  procedures 
usually  employed,  particularly  that  of  splitting  with  suture  of 
the  levators;1  the  operation  is  terminated  if  there  is  any  retro- 
deviation  by  an  indirect  hysteropexy.  This  gives  to  the  uterus 
an  inclination  almost  perpendicular  to  that  of  the  vagina,  sup- 
presses the  tendency  of  the  uterus  to  invaginate  and  thus  increases 
the  chances  of  a  definite  cure. 

Hysterectomy  is  indicated  o.nly  if  there  exists  a  concomitant 

1  It  has  been  advised  in  cases  of  hernia  of  the  pouch  of  Douglas  during  the  splitting 
operation  to  open  the  peritoneal  cul-de-sac  and  of  partially  suppressing  it.  (Frank, 
Freund,  Stratz) . 


PROPHYLACTIC  AND  MEDICAL  TREATMENT         451 

grave  lesion  of  the  uterus;  it  is  then  necessary  not  to  confine 
oneself  to  the  removal  of  the  organ  and  to  combine  with  it  a 
plastic  perineo-vaginal  operation. 

Outside  inveterate  prolapse  when  the  vagina  is  entirely 
invaginated,  hypertrophied,  and  ulcerated,  we  must  do  a  pre- 
liminary treatment  to  reduce  the  prolapse  and  to  apply  anti- 
septic applications  and  keep  the  patient  in  bed.  Hyperemia, 
edema  and  pseudo-hypertrophies  disappear  so  well  that  the 
operation  becomes  simpler. 

In  rebellious  cases  with  a  complete  tear  of  the  tissues  we 
are  sometimes  obliged  to  do  a  simple  palliative  treatment  of  a 
medical  nature. 

Treatment  of  Vaginal  Enterocele. 

Vaginal  enterocele  forms  in  the  space  between  the  uterus  and 
rectum;  stopped  below  by  the  perineum  it  presses  against  the 
vagina  and  pushes  its  posterior  wall  anteriorly  (A.  Cooper). 
Sometimes  it  is  a  simple  exaggeration  of  the  pouch  of  Douglas, 
which  may  project  into  the  vagina  and  even  out  of  the  vulva; 
sometimes  it  is  a  pediculated  tumor  of  the  posterior  wall  of  the 
vagina;  in  fact,  a  real  hernia.1 

When  we  are  dealing  with  a  pediculated  hernia,  the  most 
rational  treatment  is  the  free  opening  of  the  sac,  its  excision  at 
the  level  of  the  neck,  the  resection  of  the  exuberant  parts  of 
the  vagina  and  then  suture. 

When  we  are  dealing  with  a  protrusion  of  all  the  posterior 
wall  of  the  vagina  pressed  forward  by  the  intestine  which  dis- 
tends the  abnormally  developed  pouch  of  Douglas,  we  wrould  be 
tempted  to  combine  an  extensive  posterior  colporrhaphy  with  an 
abdominal  hysteropexy,  followed  by  obliteration  of  the  pouch  of 
Douglas  by  the  abdominal  route. 

2.  Treatment  of  Uterine  Deviations. 

The  importance  given  to  uterine  deviations  has  been  very 
varied.  For  a  long  time  they  wrere  practically  unknown;  catarrhs 
and  inflammatory  engorgements  were  the  two  principal  condi- 

1  Berger,  Vaginal  Hernias.     CongrZs  franc,  de  Chir.,  Paris,  1896,  T.  X,  p.  34. 


452  DISPLACEMENT   OF  THE   UTERUS 

tions;  then,  following  on  a  sort  of  reaction,  came  a  description  of 
the  deviations  as  essential  diseases,  in  particular  inflammatory 
states  of  the  uterus  or  adnexa.  In  fact,  uterine  deviations  rarely 
give  place  to  pathological  trouble  when  they  exist  alone;  certain 
dysmenorrheas  appear,  however,  to  be  in  relation  with  an  exagger- 
ated anteflexion  of  the  uterus;  moreover,  the  deviations  may 
contribute  to  keep  up  or  to  aggravate  inflammatory  conditions 
of  the  uterus  and  are  themselves  sometimes  a  cause  of  sterility. 
It  is,  therefore,  indicated  to  treat  them. 

Normally  the  uterus  is  in  a  state  of  slight  anteversion  with  a 
moderate  anteflexion. 

This  disposition  may  be  exaggerated  and  anteversions  and 
anteflexions  of  a  pathological  order  are  to  be  seen.  Most  often 
one  has  to  treat  retrodeviations,  retroversions  or  retroflexions. 
Finally  there  is  sometimes  an  extreme  laxity  of  the  ligaments  and 
the  uterus  oscillates  in  the  pelvis,  sometimes  being  ante  verted  and 
sometimes  retro  verted. 

In  all  cases  we  should  be  careful  to  find  out  if  there  is  any 
perineal  insufficiency,  or  metritis  or  inflammation  of  the  adnexa, 
as  these  lesions  should  be  the  object  of  special  treatment. 

Exaggerated  Mobility  of  the  Uterus. 

Among  certain .  women,  as  we  have  already  said,  we  some- 
times get  anteversion  and  sometimes  retroversion,  and  most  fre- 
quently the  latter  owing  to  the  backward  pressure  of  the  intra- 
abdominal  organs.  These  women,  who  complain  mainly  of  reflex 
nervous  trouble,  neurasthenia,  various  pains,  pains  during  walk- 
ing, have  almost  always  gastric  troubles  and  constipation.  If  they 
are  examined  with  care,  we  will  find  that  they  have  also  enterop- 
tosis,  a  vertical  dislocation  of  the  stomach,  movable  kidney, 
etc.,  etc. 

Order  them  a  belt  pressing  from  below  upward  on  the  hypo- 
gastric  region.  If  the  abdomen  is  developed  or  relaxed,  a  fortiori, 
if  there  is  enteroptosis,  we  recommend  a  belt,  which  must 
accurately  fit  the  projecting  iliac  spines  of  thin  women.  Corsets 
relieving  the  lower  abdomen  or  even  belts  with  pneumatic 
cushions,  such  as  those  of  Enriquez,  are  useful.  Finally  insert 
a  Hodge  pessary  or  one  of  its  derivatives. 


TREATMENT  OF  UTERINE  DEVIATIONS  453 

General  treatment  to  make  the  patient  stronger  and  to  calm 
her  nervous  system  should  never  be  neglected. 

Anteflexion. 

Pathologic  anteflexion  may  be  congenital  or  acquired. 

Congenital. — It  results  from  an  arrest  of  development  and  is 
habitually  associated  with  other  malformation  states  of  the 
cervix  which  is  conical,  strictured  and  obliterated,  at  the  level  of 
the  anterior  lip  and  of  the  vagina,  the  anterior  lip  of  which  is 
too  short. 

Acquired. — It  is  not  accompanied  by  any  deformity  of  the 
cervix  other  than  that  which  may  result  from  a  concomitant  in- 
flammatory state. 

It  is  distinguished  by  dysmenorrhea  and  by  a  relative  sterility. 

A  whole  series  of  operations  has  been  suggested  for  it;  some 
are  destined  to  act  on  the  cervix  and  on  the  deviation  at  the 
same  time.  The  simple  dilatation  of  the  uterus  with  laminaria 
tents  suffices  generally  to  markedly  ameliorate  the  condition  of 
the  patient. 

Retrode  viations . 

Retrodeviations  are  frequent  and  are  distinguished  by  the 
fixation  or  mobility. 

Many  fixed  retrode viations  should  be  seriously  considered; 
they  belong  to  a  class  of  lesions  which  Pozzi  calls  lesions  of  cure, 
"lesons  de  guerison."1  With  the  exception  of  renewed  attacks 
of  inflammation,  there  is  hardly  any  pain.  There  are  also 
concomitant  inflammatory  lesions  which  should  be  treated. 
The  minor  means  are  the  following:  Hot  injections,  massage, 
hydromineral  cures,  etc.,  and  in  case  of  failure,  in  women  near 
the  menopause  do  not  hesitate  to  do  a  total  castration.  In 
younger  women  be  more  conservative  and  attend  to  the  cervix, 
curette  the  body  and  reconstitute  the  perineum,  and  if  necessary 
do  not  hesitate  to  profit  by  the  anesthesia  to  open  the  abdomen 
and  liberate  the  uterus  maintaining  it  in  good  position,  by  using 
any  of  the  various  procedures  we  have  described. 

1  Pozzi,  Indications  for  Treatment  in  Retrodeviations  of  the  Uterus.     Revue  de  gyn., 
Paris,  1897,  p.  387. 


454 


DISPLACEMENT   OF   THE   UTERUS 


Mobile  Retrodeviation. — The  pathological  importance1  of 
this  condition  has  been  wrongly  denied  by  several  gynecologists. 
Various  operations  have  been  devised,  such  as  hysteropexy, 
inguinal  or  abdominal  shortening  of  the  round  ligaments,  vagino- 
fixation,  etc.  When  the  retrodeviation  is  associated  with 
another  lesion,  such  as  perineal  insufficiency,  lesion  of  the 
cervix,  etc.,  giving  rise  to  operative  intervention,  we  should  treat 
simultaneously  the  deviation  by  a  surgical  operation  which 
permits  of  an  immediate  cure.  We  should  be  authorized  also 


FIG.  362. — Lifting  up  of  the  body  of  the  uterus  with  two  fingers  inserted  into  the 
posterior  fornix,  while  the  abdominal  hand  follows  the  displacement  (Schultze). 

to  intervene  surgically  in  women  who  must  be  cured  rapidly 
to  earn  their  livelihood. 

If,  on  the  contrary,  the  woman  is  in  such  a  condition  that 
she  can  take  a  prolonged  course  of  treatment,  and  is  not  exposed 
to  fatigue,  immediately  the  question  of  orthopedic  treatment 
arises.  It  would  seem  that  there  is  a  reaction  against  the  abuse 
of  surgical  interventions,  which  were  so  widely  practised  ten 
years  ago. 

Schultze,2  who  has  always  advised  orthopedic  treatment, 
advises  the  redressing  to  be  carried  out  as  follows: 

1  Richelot,   We  Must  Redress  Retroversions.     Cong,  franc,  de   Chir.,  Paris,   1905, 
p.  306. 

2  Schultze,  Zur  Therapie  hartnackiger  Retroflexion  der  Gebarmutter.     Samml.  klin. 
Vortr.,  1891,  No.  24. 


TREATMENT  OF  UTERINE  DEVIATIONS 

In  order  to  reduce  the  organ  in  cases  of  mobile  retrodeviation 
he  lifts  up  the  body  of  the  uterus  by  means  of  two  fingers  intro- 
duced into  the  vagina,  or  into  the  rectum,  and  carrying  out  this 
manipulation  under  the  constant  control  of  the  other  hand, 
which  follows  the  organ  through  the  abdominal  wall  (Fig.  362). 
When  the  body  of  the  uterus  has  been  raised  as  far  as  the  superior 
rectus,  which  is  not  difficult  to  do  in  spite  of  pressure  which  is 
exerted  in  the  direction  of  the  arrow,  the  extremities  of  the  ringers 


FIG.  363. — After  having  exercised  a  pressure  on  the  cervix  in  the  direction  of 
the  arrow  so  as  to  help  the  redressing,  the  hand  on  the  hypogastric  hooks  the 
fundus  of  the  uterus. 

of  the  hand  on  the  hypogastrium  receive  the  fundus  of  the  uterus, 
and  convey  it  very  gently  forward,  so  as  to  leave  it  in  its 
normal  position,  behind  the  symphysis.  During  this  time,  the 
fingers  inserted  in  the  vagina  as  in  figure  364,  recognize  if 
the  superior  portion  of  the  cervix  has  preserved  its  suppleness 
and  its  normal  flexibility.  Make  certain  of  the  reduction  of 
the  redressed  organ  otherwise  it  will  reoccur.  We  now  insert 
a  pessary,  which  by  putting  tension  on  the  posterior  fornix  of 
the  vagina,  and  pushing  it  upward,  draws  the  cervix  in  that 
direction. 

Use  a  Hodge  pessary  or  better  a  Schultze,  or  Smith,  or  Thomas 
and  never  use  intrauterine   pessaries,  which   may  give  rise  to 


456 


DISPLACEMENT   OF   THE    UTERUS 


trouble.  If  a  simple  vaginal  pessary  is  not  sufficient  to  hold  the 
uterus  in  place,  it  is  because  of  perimetric  adhesions ;  the  surgical 
operation  then  is  indicated. 

Pozzi  in  France,  and  Kustner  in  Germany, 1  are  the  defenders 
of  the  bloodless  methods.  After  a  bimanual  reduction  of  the 
deviation,  they  maintain  the  uterus  with  a  pessary.  This  ought 
not  to  be  considered  as  a  simple  palliative;  it  should  permit  of 
the  consolidation  of  the  means  of  fixation  of  the  organ.  Its 
employ  is  necessarily  a  more  or  less  lengthy  period,  from  some 
months  to  some  years;  finally  a  cure  is  brought  about  and  the 
pessary  may  be  taken  out.  This  orthopedic  treatment  would 
give,  according  to  Kustner,  results  superior  to  those  of  operative 
treatment. 


FIG.  364. — The  uterus  redressed,  the  fingers  in  the  vagina  determine  the  suppleness 
of  the  superior  portion  of  the  cervix  (Schulze). 

Retroflexion  of  the  Gravid  Uterus. 

Retroflexion  often  redresses  itself  during  the  course  of  preg- 
nancy; but  this  is  not  constant  and  when  the  deviation  persists 
toward  the  fourth  month,  complications  in  the  bladder  occur, 
which  abandoned  lead  to  a  retention  of  urine  and  to  that  grave 
form  of  gangrenous  cystitis,  so  well  studied  in  France  by  Pinard 
and  Varnier.2 

1  Kustner,  Handb.  d.  Gyn.  de  Veil.,  1907,  T.  I,  p.  132. 

2  Pinard  and  Varnier,  Ann.  de  gyn.,  Paris,  1886,  T.  II,  p.  338;  1889,  T.  I,  pp.  85 
and  338. 


TREATMENT  OF  UTERINE  DEVIATIONS  457 

There  is  then  absolute  necessity  of  reducing  the  deviation  at 
this  moment.  In  general  it  is  very  easy,  and  in  all  cases  we 
have  observed  we  have  been  able  to  do  it  by  simply  pushing 
back  the  fundus  of  the  uterus  into  position  with  the  extremities 
of  the  two  fingers  engaged  in  the  vagina,  and  making  it  pass 
from  below  upward  along  the  concavity  of  the  sacrum.  It  is 
important  not  to  act  on  the  angle  of  flexion,  but  to  commence 
the  reduction  by  acting  upon  the  most  posterior  portion  of  the 
fundus  of  the  uterus.  The  organ  having  been  redressed  stays 
in  place  if  the  reduction  has  been  done  toward  the  fourth 
month,  at  the  time  when  vesical  troubles  appear.  The  uterus 

is   then    of   such   a    volume   that    it  cannot  fall  back  into  the 

/ 

pelvic  excavation. 

In  exceptional  cases,  where  by  reason  of  adhesions  the  manual 
reduction  is  impossible,  then  one  may  open  the  abdomen,  break 
down  the  adhesions  and  redress  the  uterus.1  Some  gynecologists 
do  an  anterior  fixation  of  the  organ  and  insert  a  pessary.  These 
manipulations  are  only  to  be  thought  of  if  the  pregnancy  is  very 
early;  if  it  is  near  the  fourth  month,  they  are  useless,  and  we 
should  content  ourselves  with  simple  redressing  of  the  uterus  as 
we  have  already  indicated  when  speaking  of  the  manual  redress- 
ing of  the  uterus  when  vesical  troubles  come  on. 

Uterine  Inversion. 

Uterine  inversion  may  result  from  a  fibrous  polyp  or  follow 
on  an  accouchement. 

Puerperal  Inversion. — Whatever  the  form  or  age  of  the  inver- 
sion, the  surgeon  should  first  of  all  seek  to  do  the  reduction  by 
simple  means.  If  the  placenta  remains  adherent  to  the  fundus 
of  the  inverted  uterus,  commence  by  separating  it  and  then 
reduce  it. 

This  is  most  often  done  by  manual  taxis.  The  cervix  is  held 
firmly  by  forceps  in  the  hands  of  an  assistant,  who  continues  a 
sustained  traction.  The  operator  with  the  left  hand  presses  down 
the  abdominal  wall,  and  immobilizes  the  uterus;  with  his  right 
hand  introduced  into  the  vagina,  he  compresses  the  body  of  the 
uterus,  renders  it  supple,  and  then  endeavors  to  reduce  it,  always 

1  Frankenstein,  Deuisch.  med.  Woch.,  Leipzig,  1910,  p.   1038.     Maiss,  Monatschr.  f. 
Geb.  und  Gyn.,  Berlin,  1910,  T.  I,  p.  773.     Cristofoletti,  Gyn.  Rundschau,  1910,  p.  446. 


458  DISPLACEMENT   OF   THE   UTERUS 

endeavoring  to  find  the  point  by  which  reduction  is  most  easily 
carried  out.  In  general  pressure  on  the  fundus  is  inefficacious, 
and  it  would  be  better  to  begin  with  the  parts  near  the  pedicle. 
Pinard  insists  on  two  points :  only  to  commence  taxis  after  having 
pushed  the  uterus  back  into  the  vagina;  second,  only  to  use  trac- 
tion in  the  interval  between  contractions,  if  one  performs  reduc- 
tion immediately  after  confinement. 

Slow  Methods. — Replace  the  manual  action  by  a  continuous 
pressure  carried  out  for  several  days :  first,  by  tamponing ;  second, 
by  instruments  acting  on  the  fundus  of  the  uterus  by  a  rigid  stem, 
the  pressure  being  administered  by  an  undrainable  bandage  or 
English  repositor ;  third,  by  pressure  with  air  and  water  pessaries, 
Braun's  and  Champetier's  bags,  which  give  a  certain  number  of 
good  results. 

These  methods  have  the  inconvenience  of  their  lengthy  dura- 
tion and  pain  they  cause,  the  complications  which  they  may  cause, 
such  as  fever  and  pelvic  peritonitis,  etc. 

Whatever  the  procedure  employed,  once  reduction  is  obtained, 
give  a  little  ergotine  and  tampon  the  uterine  cavity  with  iodoform 
gauze. 

If  one  fails  or  if  the  uterus  appears  to  be  threatened  with 
gangrene,  we  must  do  our  reduction  by  a  surgical  operation,  either 
by  the  abdominal  or  better  by  the  vaginal  route.  Vaginal  hys- 
terectomy is  only  indicated  if  there  are  grave  hemorrhages  which 
threaten  life  immediately  or  if  the  inverted  organ  presents  mani- 
fest signs  of  gangrene.  The  old  procedures,  of  removal  of  the 
inverted  portion  with  a  crushing  instrument  or  serre-noeud  or 
elastic  ligature,  which  wrere  used  for  the  purpose  of  destroying  the 
arteries  and  peritoneum  before  the  prolapse  of  the  organ,  have  all 
been  abandoned  to-day. 

Polypoid  Inversion. — The  first  indication  to  fulfill  is  to 
remove  the  myoma.  As  it  is  often  difficult  to  say  where  the  tumor 
exactly  ends  and  the  true  tissue  of  the  uterus  begins,  it  is  well  not 
to  do  there  and  then  a  section  close  up  to  what  appears  to  be  the 
insertion  of  the  polyp.  Taking  hold  of  the  protruding  portion 
of  the  polyp  with  forceps,  it  is  split  vertically  by  degrees  until 
we  reach  the  deep  part  of  its  cortex;  nothing  is  simpler  then 
than  to  enucleate  it.  In  a  certain  number  of  cases  as  soon  as 
one  has  removed  the  tumor  which  draws  upon  the  fundus  of  the 


TREATMENT  OF  UTERINE  DEVIATIONS  459 

uterus,  it  reduces  of  itself.  If  not  we  may  proceed  to  the  reduction 
as  in  puerperal  inversion.  As  in  these  cases  we  are  generally 
concerned  with  .women  of  a  "certain  age,"  the  uterus  frequently 
contains  fibrous  nodules  and  thus  the  indications  of  the  radical 
operation  are  increased,  and  we  can  resolve  more  easily  to  do 
vaginal  hysterectomy  than  in  puerperal  inversion. 


CHAPTER  IV. 

EXTRAUTERINE  PREGNANCY. 

Summary. — General  indications  of  treatment  of  extrauterine  pregnancy. 
— T.  of  pregnancy  during  the  first  five  months  in  absence  of  complications. — 
T.  of  the  peritoneal  hemorrhage  of  encysted  hematocele  either  intra-  or 
subperitoneal. — T.  of  pregnancy  after  the  fifth  month,  old  fetal  cysts. 

In  the  course  of  its  evolution  extrauterine  pregnancy  may  be 
attended  by  numerous  complications.  In  the  primary  period 
that  most  to  be  feared  is  hemorrhage,  which  may  be  very  abun- 
dant, constituting  thus  a  veritable  peritoneal  inundation,  placing 
the  life  immediately  in  danger  or  failing  that  it  may  lead  to  the 
formation  of  hemorrhagic  collections  in  the  pouch  of  Douglas, 
such  as  retrouterine  hematoceles,  or  more  exceptionally  to  sub- 
peritoneal  effusions  or  intraligamentary  hematoceles.  At  a  more 
advanced  period,  when  she  approaches  term,  the  extrauterine 
pregnancy  may  be  the  cause  of  complications.  Finally  after  the 
death  of  and  partial  absorption  of  the  fetus,  the  lithopedion  and 
the  sac  containing  the  skeleton  may,  by  reason  of  the  development 
of  adhesions,  cause  abdominal  troubles.  At  all  periods,  therefore, 
infection  is  possible,  as  the  sac  may  suppurate  and  as  we  have 
seen  after  long  years  of  silence,  a  lithopedion  may  inflame,  sup- 
purate, and  open  into  the  bladder  or  rectum. 

Also,  in  presence  of  an  extrauterine  pregnancy,  we  must  act 
quickly. 1 

Formerly,  the  death  of  the  fetus  was  aimed  at  either  by  modi- 
fying the  health  of  the  mother  by  hunger,  by  hemorrhages,  or 
by  administration  of  strychnine  in  slightly  toxic  doses,  or  directly 
by  the  death  of  the  ovum  by  electrical  applications  or  injections 
of  morphia. 

1  Runge,  Beitr.  z.  Aetiol.  Sympt.  u.  Therapie  de  Extrauteringraviditat.  Arch.f.  Gyn., 
1903,  T.  LXX,  fasc.  3.  Segond,  Treatment  of  Extrauterine  Pregnancies,  Cong,  franc, 
d'obst.,  gyn.  et  ped.,  second  session,  Marseilles,  1898,  and  Revue  de  gyn.,  Paris,  1898, 
p.  801.  O.  Kustner,  Ueber  Extrauterinschwangerschaft.  Samml.  klin.  Vortrag., 
Leipzig,  1899,  No.  244. 

460 


PREGNANCIES  IN  THE  FIRST  FIVE  MONTHS  461 

To-day  its  treatment  is  exclusively  surgical. 

Every  extrauterine  pregnancy  when  diagnosed  should  be 
operated  on.  Some  years  have  elapsed  since  Martin  showed  that 
by  expectant  treatment  we  got  16.9  per  cent,  of  cures  and  by 
operation  76.7  per  cent.  We  should  like  to  add  that  if  interven- 
tion is  early  the  percentage  of  cures  is  still  higher.  Kustnerin 
107  cases  had  only  two  deaths,  one  of  wrhich  was  from  peritonitis 
in  a  patient  with  hepatic  cirrhosis,  when  the  operation  had  been 
long  and  in  the  other,  a  woman  who  was  anemic  from  former  hem- 
orrhages which  were  extremely  abundant.  Strauch  (Mosco\v) 
operated  91  tubal  pregnancies  and  had  no  deaths. 

From  the  point  of  view  of  indications  to  fulfill  it  is  well  to 
divide  them  into  those  cases  before  and  after  five  months  of 
pregnancy. 

1.  Pregnancies  Observed  in  the  Course  of  the  First  Five 
Months. — If  there  are  no  complications,  some  gynecologists 
carry  out  an  expectant  treatment,  holding  themselves  in  readiness 
for  the  least  sign  of  danger.  It  is  a  line  of  conduct  which  would 
permit  of  argument  if  the  ovum  were  dead  or  if  there  had  been 
an  expulsion  of  a  decidual  membrane,  but,  if  the  ovum  were 
continuing  to  evolve,  it  cannot  be  considered  seriously  for  a 
moment. 

Generally,  the  removal  of  the  gravid  tube  is  done  by  the  abdom- 
inal route;  in  some  cases  on  intervention  has  been  essentially 
conservative,  and  some  surgeons  have  removed  successfully  a 
tubal  mole  after  incision  of  the  tube,  and  have  afterward  sutured 
the  incision,  which  treatment  seems  hardly  suitable  to  moles  in 
this  stage  of  retrogression.1  Total  castration,  advocated  for  the 
purpose  of  putting  an  end  to  all  recurrences,  appears  a  contraindi- 
cation to  us.2  We  have  seen  a  number  of  our  operated  cases  have 
a  series  of  normal  pregnancies  after  removal  of  a  pregnant  tube, 
and  hence  we  do  not  advocate  castration  unless  at  the  same  time 
there  is  an  inflammation  of  the  adnexa  on  the  opposite  side,  or 
in  short,  lesions  which  of  themselves  demand  removal. 

In  rare  cases  of  tubo-interstitial  pregnancy  do  a  hysterectomy, 
with  the  intrauterine  opening  of  the  sac  by  a  sound  passed  by  the 
dilated  cervix  (H.  Kelly),  a  practice  which  will  be,  so  we 

1  Muret,  Rev.  de  gyn.,  Paris,  1898,  p.  195. 

2  Sens,  Critical  Study  of  Eighty-nine  Observations  of  Recurrent  Ectopic  Gestation, 
Th.  de  Paris,  1901,  No.  202. 


462  EXTRAUTERINE  PREGNANCY 

think,  little  followed.  In  such  a  case  we  are  tempted  to  do  a 
wedge-shaped  excision  of  the  uterus,  as  well  as  a  removal  of  the 
tube  followed  by  suture,  and  when  we  have  to  deal  with  an  inun- 
dation of  the  peritoneum,  the  immediate  operation  is  indicated. 
On  this  score  the  danger  of  shock  enters  in  and  possible  errors 
of  diagnosis.  These  objections  have  no  value.  With  large 
injections  of  serum,  either  if  occasion  requires  intravenous,  we 
do  not  fear  shock  in  these  cases.  As  to  errors  of  diagnosis,  such 
as  intestinal  obstruction,  torsion  of  the  pedicle  of  a  tumor,  etc., 
these  demand  the  immediate  opening  of  the  abdomen  and  do  not 
contraindicate  operation. 

Expectant  treatment  gives  86  per  cent,  of  deaths,  and  opera- 
tion 85  per  cent,  of  cures. 

If  we  have  a  hematocele  the  operation  is  indicated  all  the 
same.  It  should  be  done  abdominally  if  there  are  successive  at- 
tacks showing  that  hemostasis  is  not  complete.  It  is  then  indi- 
cated not  only  to  remove  clots  but  to  find  the  bleeding  point  and 
tie  it;  then  remove  the  bleeding  tube,  completely  closing  the  ab- 
domen and  leaving,  without  drainage,  the  blood  which  has  not 
been  evacuated  during  the  operation.  In  such  cases  the  simple 
vaginal  incision  which  leads  to  a  continuation  of  hemorrhage 
should  be  rejected. 

On  the  contrary,  if  the  hematocele  is  well  encysted,  and 
particularly  if  it  is  infected  colpotomy  is  indicated.  Exceptionally 
in  certain  cases  of  pelvic  subperitoneal  hematocele  or  inguinal 
hematocele  in  order  to  evacuate  the  seat  of  trouble,  wre  do  an 
ischio-rectal  incision  (Lejars),  or  an  inguinal  subperitoneal 
incision  (Pozzi).  The  indication  is  always  the  same,  that  is,  to 
go  to  the  spot  where  the  collection  points  and  incise  and  drain  it. 

2.  Pregnancy  After  the  Fifth  Month. — If  the  fetus  has  passed 
35  to  36  weeks,  it  is  viable ;  we  must  operate  immediately  without 
waiting  false  labor,  because  at  that  time  the  infant  dies  rapidly, 
and  the  pains  use  up  the  mother's  strength  and  place  her  in  a 
less  favorable  operative  condition. 

If  the  fetus  is  living  but  is  not  yet  viable,  opinions  are  divided. 
Some  say  that  the  mother  only  should  be  thought  of  and  that 
an  intervention  should  be  made.  This  idea  is  founded  on  the 
fact  that  complications  may  occur  and,  also  that  the  fetus  is 
frequently  doomed  or  if  it  arrives  at  term  is  malformed.  Others 


PREGNANCIES  IN  THE  FIRST  FIVE   MONTHS  463 

find  that  there  is  a  real  exaggeration  in  the  operative  indications, 
and  that  one  should  wait,  and  give  time  to  the  fetus  to  develop, 
and  that  one  should  exercise  a  continuous  watch  over  the  patient, 
being  ready  to  operate  if  the  least  complication  arises,  or  if  the 
mother  becomes  enfeebled. 

When  tKe  operation  is  decided,  we  must  determine  by  what 
route  to  do  the  intervention  ?  Some  gynecologists,  particularly 
in  Germany,  operate  by  the  vagina.  This  route  is  dangerous 
if  the  placenta  is  inserted  in  the  pelvis ;  the  extraction  of  the  infant 
is  dangerous  and  often  there  is  great  difficulty  in  stopping  any 
hemorrhage. 

We  should  operate  by  the  abdomen,  open  the  sac  at  a  point 
where  it  is  thin,  draw  out  the  infant  by  the  feet  and  tie  the  cord. 
Then  comes  the  crux  of  the  question.  Some  operators,  fearing  a 
prolonged  suppuration  and  hernias  following  and  finding  that 
the  sac  is  friable  and  difficult  to  fix,  wish  to  remove  both  sac  and 
placenta.  Others,  desirous  of  avoiding  hemorrhages  which 
'sometimes  follow  immediately  after  separation  of  the  placenta, 
advocate  the  marsupialization  of  the  sac,  and  await  the  spon- 
taneous separation  of  the  placenta.  The  line  of  conduct  is 
advised  by  Baudelocque,  and  supported  by  Pinard,  who  had 
16  cures  in  17  cases. 

We  should  distinguish  between  cases.  If  the  fetus  is  free 
in  the  peritoneal  cavity,  or  if  during  the  primary  maneuvers 
there  is  a  partial  separation  of  the  placenta  and  a  consequent 
hemorrhage,  then  removal  is  necessary.  If  the  enucleation 
seems  easy  and  there  is  no  insertion  of  the  intestine  on  the  pla- 
centa, then  hemostasis  of  the  tube  or  of  the  epiploon  is  easily 
procured,  and  removal  is  a  matter  of  discussion;  personally, 
we  advise  it  because  it  is  a  means  of  cutting  short  the  duration 
of  the  treatment.  If  the  placenta  is  inserted  only  partially 
into  the  intestines,  we  should  have  no  hesitation  in  leaving  it. 

If  the  fetus  is  dead,  indications  of  an  immediate  operation 
present  themselves,  such  as  hemorrhage,  peritonitis,  etc.,  etc. 
In  absence  of  complications  it  is  better  if  the  death  is  recent  to 
wait  some  time,  as  the  intercystoplacental  circulation  progres- 
sively diminishes.  It  is  prudent  not  to  wait  too  long,  and  to 
operate  before  six  weeks'  time  because  of  the  congestion  which 
accompanies  a  return  of  menstruation. 


464  EXTRAUTERINE  PREGNANCY 

Intervention  is  often  indicated  later  and  we  should  not  wait 
until  a  lithopedion  forms. 

Finally,  if  we  have  to  deal  with  an  old  fetal  cyst,  tolerated  with- 
out any  complications,  or  having  a  fortiori  suppurated,  we  should 
operate.  The  fetal  cyst  should  be  removed  like  a  cyst  anywhere 
else:  the  suppurating  cyst  should  be  opened  where  it  points,  and 
the  lithopedion  should  be  taken  out  and  drainage  made  of  the 
pocket. 

In  a  single  case,  the  rule  that  one  should  open  where  it  points, 
ought  not  to  be  followed,  and  that  is  when  the  cyst  points  in  the 
rectum;  even  then,  if  there  is  a  beginning  fistula  in  the  intestine, 
it  is  preferable  to  do  a  free  posterior  colpotomy  in  such  a  way  as 
to  drain  it,  and  to  make  repeated  lavage  of  the  pocket,  and  thus 
endeavor  to  get  a  cure  of  the  rectal  fistula.  As  to  cysts  opened 
in  the  bladder,  they  may  be  very  simply  cured  by  simple  evacua- 
tion through  the  dilated  urethra,  if  the  fetus  has  not  yet  attained 
five  months ;  if,  on  the  contrary,  the  fetus  is  older  than  five  months, 
we  should  be  forced  to  do  a  more  complex  intervention,  either  by 
the  endovesical  route  or  the  intraperitoneal. 


CHAPTER  V, 

MENSTRUATION  TROUBLES  AND  STERILITY. 

Summary. — Menstruation  troubles. — Primary  or  secondary  amenor- 
rhea. — Menorrhagia  and  metrorrhagia. — Dysmenorrhea. — Troubles  of  the 
menopause. — Treatment  of  sterility. 

1.  Troubles  of  Menstruation. 

Under  the  name  of  menstruation  is  understood  a  discharge  of 
blood  from  the  uterus  at  certain  regular  intervals  during  the 
sexual  life  of  woman,  which  normally  varies  from  13  and  15  to 
45  and  50  years. 

This  discharge  may  not  occur,  amenorrhea;  or  may  be  too 
abundant,  menorrhagia ;  or  occur  with  difficulty,  dysmenorrhea ; 
finally  its  cessation  may  be  accompanied  by  a  series  of  complica- 
tions at  the  critical  period  called  the  menopause. 

I.  Amenorrhea. 

Amenorrhea  may  be  primitive,  as  menstruation  does  not  occur 
at  the  regular  age ;  it  results  from  a  simple  retard  in  the  establish- 
ment of  menstruation  from  an  arrest  in  the  development  of  the 
reproductive  organs,  or  from  an  atresia,  which  may  occur  at 
various  points  in  the  genital  canal,  and  preventing  blood  from 
issuing  externally.  In  this  case  it  is  not  strictly  speaking  amenor- 
rhea, but  a  menstrual  retention. 

In  presence  of  a  primary  amenorrhea  the  first  point  is  to 
discover  if  the  amenorrhea  is  due  to  an  arrest  of  development  or 
menstrual  retention.  An  examination  of  the  genital  organs  in  a 
young  virgin  is  always  a  delicate  matter.  We  should  in  the 
absence  of  menstrual  molimen  temporize,  in  the  hope  that  it  is 
simply  a  retard  in  the  appearance  of  menstruation,  treating  the 
anemia  if  it  exist,  and  make  her  lead  a  life  in  the  open  air,  treating 
the  constipation  which  according  to  Kelly  is  always  associated  with 
amenorrhea.  If,  on  the  contrary,  the  young  girl  suffers  period- 

30  465 


466  MENSTRUATION   TROUBLES   AND   STERILITY 

ically,  there  is  probably  a  menstrual  retention,  and  we  should 
then  do  a  genital  examination  and  treat  the  hymeneal  or  vaginal 
imperforations  as  soon  as  these  are  discovered. 

If  this  examination  demonstrates  an  arrest  of  development 
in  the  uterus,  one  is  almost  at  a  loss  to  do  anything.  Also,  if 
ovarian  pains  are  excessive  and  nothing  can  ease  them,  do  an 
ovarian  castration.  Knowing  the  action  of  X-rays  on  the  ovaries, 
we  might  be  tempted  to  do  some  radiotherapy.  We  do  not  know 
if  it  has  already  been  tried,  but  it  appears  to  us  that  attempts 
might  be  made. 

If  there  is  no  pain,  and  no  trouble  but  the  absence  of  menstrua- 
tion, we  should  content  ourselves  with  a  general  treatment,  so  as  to 
cause  the  patient  to  turn  her  thoughts  from  her  genital  organs. 

Secondary  amenorrhea  or  suppression  of  menstruation  may 
be  due  to  varied  causes.  The  first  idea  that  the  gynecologist 
conceives  is  that  of  pregnancy,  but  after  having  proved  this  not 
to  be  the  case  we  must  look  for  other  causes  of  amenorrhea. 

Cicatricial  atresias  are  exceptional;  generally  it  is  due 
to  constitutional  trouble  (chlorosis,  tuberculosis,  acute  or 
chronic  diseases,  obesity,  etc.)  or  functional  (change  of  cli- 
mate or  regime  or  nervous  exhaustion,  etc.).  The  treatment 
consists  in  treating  the  cause.  Emmenagogues  such  as  rue, 
sabine,  apiol,  etc.,  have  not  any  well  demonstrated  action.  We 
may  use  saline  and  drastic  purgatives,  permanganate  of  potash, 
electricity  (faradic  currents,  continuous  currents,  static  bath  with 
sparks  drawn  from  the  lumbar  region) . 

With  amenorrhea  is  sometimes  associated  supplementary 
menstruation,  vicarious  or  ectopic,  a  hemorrhagic  discharge 
occurring  from  the  nose,  stomach,  intestine,  etc.  This  supple- 
mentary mensturation  is  sometimes  a  cause  of  relief  to  the  patients 
which  should  be  respected;  exceptionally  if  it  becomes  so  abun- 
dant as  to  endanger  life,  we  may  be  forced  to  remove  the  ovaries 
(Webster,  Fischel). 

II.  Menorrhagia  and  Metrorrhagia. 

Menorrhagia  is  only  an  exaggeration  of  the  normal  flow. 
Metrorrhagias  are  hemorrhages  which  occur  betwreen  menstrual 
periods.  Sometimes  it  exists  in  connection  with  general  disease 


TROUBLES  OF  MENSTRUATION  467 

by  alteration  of  the  blood  (hemophilia,  scorbutus,  grave  icterus, 
phosphorus  poisoning,  cachectic  states,  and  the  commencement 
of  certain  pyrexias),  and  most  often  in  connection  with  a  local 
lesion  connected  generally  with  the  uterus  demand,  and  these 
hemorrhages  usually  an  indirect  treatment,  that  of  their  cause. 
We  will  make  a  special  mention  of  certain  menorrhagias  of  the 
young  girl,  which  appear  to  be  mainly  of  functional  origin,  and 
combined  with  vasomotor  troubles  brought  on  by  a  relaxation  of 
the  tissues  following  on  their  rapid  development  at  puberty. 
They  demand  a  general  treatment. 

As  uterine  hemostatics  we  may  recommend  repose  in  bed, 
hot  vaginal  injections  at  48°  to  50°,  ergotine  by  the  stomach  or 
subcutaneously,1  hydrastis  canadensis,2  stypticine,3  adrenal- 
ine,4 choloride  of  calcium,5  electrical  applications  and  vaginal 
or  uterine  tamponing. 

III.  Dysmenorrhea. 

It  is  very  frequent  to  see  women  complain  of  pain  in  the  pelvis, 
back,  and  thighs,  and  of  a  slight  nervous  excitability  at  the  time  of 
menstruation.  We  cannot  say  that  there  is  dysmenorrhea  except 
in  cases  where  the  increase  in  these  troubles  becomes  pathological. 
The  pains  may  sometimes  be  such  that  the  patients  have  to  take 
to  bed,  covered  with  sweat,  the  extremities  cold  and  they  some- 
times lose  consciousness;  sometimes  they  have  nausea  and 
vomiting. 

It  is  difficult  to  give  precise  therapeutic  indications  for  the 
treatment  of  dysmenorrhea,  as  the  causes  of  the  troubles  are 
still  very  imperfectly  known.  In  certain  gross  lesions  (pelvic 
inflammations,  myomas,  retroflexions) ,  a  causal  treatment  is 
necessary.  Unhappily,  in  the  majority  of  cases,  the  cause  is  not 
precise.  Mechanical  dysmenorrhea  has  been  described.  An 
acute  curve  in  the  cervical  canal,  a  contraction  of  one  of  the  ori- 
fices of  the  cervix,  a  clot  or  membrane  preventing  the  flowr  of 

1  Seigle  ergot  10  to  60  centigrams  daily,  in  pills  or  cachets;  Yvon  ergotine,  a  centi- 
meter cube  injected  subcutaneously  night  and  morning. 

2  Fluidextract  of  hydrastis  hamamelis,    viburnum,    10  grams  of  each  daily:  take 
thrice  daily  20  drops  of  this  solution  in  a  little  water. 

3  Four  to  six  tablets  or  capsules  daily  containing  5  centigrams  of  stypticine. 

4  Fifty  centigrams  to  1  gram  of  1  to  1000  solution  subcutaneously. 

6  Four  grams  daily  in  a  potion  of  150  cm.  cubes  to  be  taken  by  soupspoonfuls  every 
two  hours. 


468  MENSTRUATION   TROUBLES  AND   STERILITY 

hemorrhage;  this  theory  is  much  discussed  to-day.  That  which 
is  generally  admitted  is  that  in  dysmenorrhea  there  is  a  spasmodic 
state  of  the  uterus  of  which  the  cause  is  imperfectly  known. 

When  the  pains  appear  give  sedatives  (phenacetine,  pyra- 
midon,  chloral,  valerianate  of  ammonia,  antipyrin,  etc.),  applica- 
tions of  hot  wTater  bags  to  the  abdominal  wall  and  mustard  baths 
for  the  feet. 

With  the  exception  of  menstruation,  endeavor  to  stimulate 
the  general  state  by  repose,  in  particular  after  the  midday  meal ; 
and  by  a  substantial  alimentation,  by  a  calm  life  in  the  open  air 
and  by  regular  evacuations. 

Uterine  dilatation  is  sometimes  useful;  curettage  followed 
by  applications  of  iodine,  carbolic  acid,  and  glycerine,  etc.,  have 
been  advised.  Fleiss  says  that  applications  to  certain  points  of 
the  nasal  mucous  membrane  with  a  strong  solution  of  cocaine 
stops  the  pains,  and  has  described  sexual  points  in  the  nose. 
Kolischer  has  obtained  analogous  effects  by  cocainizing  other 
mucous  membranes:  that  of  the  cervix  uteri  and  rectum,  and 
it  would  seem  to  be  due  to  suggestion.  The  ingestion  of  ovarian 
preparations  wras  advocated  by  Gibbons. 

In  incurable  cases,  do  ovariectomy;  this  is  authorized,  if  the 
continuity  of  the  pains  affects  the  general  state.  Still  it  is  not 
certain  that  all  these  troubles  wrould  follow  on  this  mutilation. 

IV.  Troubles  of  the  Menopause. 

When  the  menopause  comes  and  even  more  after  the  artificial 
menopause  produced  by  bilateral  castration,  we  sometimes  see 
a  series  of  troubles  follow,  which  persist  in  certain  people  during 
many  years ;  these  are  heat  flushings,  insomnia,  pain  in  the  head, 
migraines,  a  neuro-muscular  or  psychic  neurasthenia  and  some- 
times obesity. 

Walking  in  the  open  air,  motor  trips,  and  absence  of  excessive 
physical  excitation  and  moral  emotion,  a  regime  for  obesity, 
and  regular  action  of  the  intestine  constitutes  the  general  base 
of  the  treatment. 

Against  these  heat  flushings  and  nocturnal  sweatings,  wre 
find  that  hot  baths  about  40°  are  often  very  useful.  Ovarian 
opotherapy  is  very  useful.  As  the  ingestion  of  the  raw  ovary  is 


STERILITY  469 

very  often  repugnant  to  patients,  give  ovarine,  powder  of  desic- 
cated ovary  or  ocreine,  dried  corpora  lutea,  based  on  the  idea 
that  the  corpus  luteum  is  the  active  part  of  the  ovary.1 

By  these  means  we  find  a  notable  amelioration  in  the  state 
of  the  patients. 

2.  Sterility. 

The  number  of  sterile  marriages  is  about  the  same  in  different 
countries,  oscillating  between  11  and  13  per  100.  Formerly  it 
was  customary  to  impute  the  sterility  to  the  woman.  It  is  known 
to-day  that  in  46  per  cent,  of  cases  sterility  is  dependent  on  the 
husband,  exceptionally  due  to  loss  of  puissance,  but  generally 
due  to  azoospermia;  that  in  12  to  13  per  cent,  of  cases,  it  results 
indirectly  from  the  husband,  who  has  transmitted  gonorrhea  to 
his  wife,  rendering  her  sterile,  so  that  in  59  per  cent,  of  cases  the 
guilty  person  is  the  husband  (Sanger).  We  should  always  think 
of  this  wrhenever  a  woman  comes  to  consult  us  in  order  to  have 
children.  The  treatment  of  sterility  in  woman  should  never  be 
undertaken  until  an  examination  is  first  made  of  the  husband  to 
determine  the  state  of  his  generative  functions. 

Once  the  state  of  the  husband  is  found  satisfactory,  in  order 
to  treat  sterility  well,  find  out  the  cause. 

The  history,  especially  that  dealing  with  the  study  of  the 
physiognomy  of  menstruation,  gives  as  Pinard  remarks,  important 
information. 

A  woman  who  commenced  to  menstruate  at  12  to  15  years, 
and  whose  menstruation  has  always  been  painful,  particularly 
in  the  first  twenty-four  hours,  has  probably  a  flexed  uterus,  with 
more  or  less  contraction  of  the  canal. 

A  woman  who  menstruates  late,  from  16  to  20  years,  and 
irregularly,  losing  little*,  and  complaining  of  pains  about  the 
ovaries,  is  a  woman  whose  ovular  evolution  is  difficult  and 
imperfect.  Often  it  is  a  thin  woman  with  hereditary  antecedents 
of  rheumatism;  gout,  arthritic  troubles,  and  antecedent  personal 
history  of  urticaria,  migraine  and  herpes,  etc. 

A  woman  who  commenced  normally  to  menstruate,  but  loses 

1  Give  two  sheep  ovaries  daily  or  10  to  30  centigrams  of  ovarine  one-quarter  of  an 
hour  before  meals. 


470  MENSTRUATION   TROUBLES   AND   STERILITY 

less  and  less  and  at  longer  intervals,  is  often  affected  with  preco- 
cious and  exaggerated  embonpoint;  in  such  a  case  the  ovules 
no  longer  mature. 

In  a  woman  whose  menstruation  is  normal  at  the  commence- 
ment, but  which  becomes  more  frequent  and  abundant  and  con- 
tains clots  has  generally  a  fibromatous  uterus. 

Having  put  our  questions,  wre  should  proceed  to  the 
direct  examination  with  the  object  of  finding  out  if  there  exists 
an  obstruction  either  preventing  the  progression  of  the  ovule 
toward  the  uterus  or  the  ascension  of  spermatozoa,  or  a  patholog- 
ical state  of  the  endometrium  preventing  the  fixation  of  the 
fertilized  ovule.  In  very  exceptional  cases  we  may  find  that 
the  woman  is  a  virgin.  Vaginal  examination  combined  with  pal- 
pation will  show  us  deformities,  uterine  deviations,  and  the 
existence  of  false  vaginal  routes,  etc.  The  examination  with 
a  speculum  may  show  a  thick  opaque  or  yellowish  obstruction 
or  cork,  as  the  French  express  it,  on  the  cervix. 

The  results  of  this  examination  will  give  indications  of  treat- 
ment. 

Metritis,  uterine  fibromata,  uterine  deviations,  stenosis  or 
inflammatory  states  of  the  cervix  may  be  treated  in  the  usual 
way.  In  uterine  flexion,  dilatation  and  redressing  with  lami- 
naria  tents,  followed  by  dilatation  with  a  catheter  and  followed  by 
Hegar's  bougies  renders  splendid  service. 

If  it  is  a  case  of  imperfect  ovulation,  Pinard  recommends 
an  absolute  milk  regime  at  intervals  during  one  or  two  months. 
The  obesity  disappears,  the  menstruation  becomes  normal  and 
fecundation  soon  occurs. 

In  cases  of  irregular  menstruation,  at  first  small  with  an 
infantile  uterus  (enlarged  cervix  with  a  very  little  body) ,  we  must 
have  patience  and  abstain  from  all  surgical  intervention,  and  be 
content  to  favor  the  general  development  of  the  organism  by 
exercise,  a  suitable  hygiene  and  thermal  cures. 

Static  electricity  often  renders  service  in  women  where  the 
uterus  is  normal  and  the  menstruation  ceased  suddenly. 

Temporary  repose  for  the  genital  organs,  and  alkaline  vaginal 
injections  are  useful  adjuvants  of  treatment  in  nervous  wromen. 


PART  V. 
OPERATIONS  ON  THE  URINARY  APPARATUS. 

CHAPTER  I. 

CHEMICAL  EXAMINATION  OF  THE  URINARY  APPARATUS  OF 

WOMAN. 

Summary. — Questions,  frequency  and  pain  of  micturition. — Examina- 
tion of  urine. — Examination  of  the  urethra  (meatus,  Skene's  glands,  canal). — 
Examination  of  the  bladder  (percussion,  palpation,  catheterization,  cystos- 
copy). — Examination  of  the  ureters  (vaginal  examination). — Examination 
of  the  kidneys. — Intravesical  separation  of  the  urine. — Catheterization  of  the 
ureters. 

1.  Interrogation. — If  we  have  to  deal  with  a  woman  who  com- 
plains of  urinary  troubles  we  should  begin  by  hearing  the  patient 
and  then  questioning  her. 

1.  Inquire  into  the  state  of  micturition,  its  frequency  and 
pain  that  accompanies  it. 

(a)  Frequency. — Is  the  patient  required  to  urinate  frequently  ? 
Is  it  continuous  during  the  twenty-four  hours  or  only  diurnal  ? 
or  nocturnal  ?  If  the  frequency  prevent  her  sleeping  is  it  due 
to  cystitis  ? 

If  the  frequency  ceases  in  the  recumbent  position,  and  only 
exists  in  the  standing  position  or  while  walking,  we  may  conclude 
the  vesical  symptoms  have  as  origin  a  lesion  of  the  neighboring 
parts.  It  is  generally  a  question  of  a  uterine  affection,  a  uterus 
too  heavy  for  its  means  of  suspension,  perhaps  due  to  a  sclerous 
hypertrophy  of  inflammatory  origin,  or  to  its  means  of  sup- 
port having  disappeared,  as  that  happens  in  perineal  tears  with 
prolapse. 

(6)  Pain. — When  does  the  patient  suffer  ? 

Before,  during  or  after  micturition  ? 

Pain  during  micturition  indicates  a  urethral  inflammation. 

Pain  after  indicates  an  inflammation  of  the  bladder. 

471 


472       CHEMICAL  EXAMINATION   OF   THE   URINARY   APPARATUS 

2.  We  can  thus  rapidly  get  an  idea  of  the  general  state  of  the 
patient  and  of  her  various  functions. 

2.  Examination  of  the  Urine. — After  questioning  the  patient, 
we  should  proceed  to  an  examination  of  the  urine. 

To  do  this  with  a  man,  wre  use  several  glasses;  the  first  con- 
tains the  secretions  of  the  canal  and  indicates  the  state  of  the 
anterior  urethra,  while  the  second  denotes  the  state  of  the  pos- 
terior urethra  and  bladder. 

This  separation  is  less  important  in  case  of  women  because 
the  urethra  is  short  and  the  secretions  less  abundant.  However, 
it  has  its  importance;  thus  if  the  patient  micturates  in  two  or 
three  glasses,  the  first  indicates  the  state  of  the  urethra;  the  two 
others  the  state  of  the  bladder.  Above  all  the  third,  which  is 
obtained  by  the  expression  of  the  contracted  bladder  against  the 
neck  of  the  bladder. 

I  will  not  insist  here  on  the  character  of  pyuria  or  hematuria, 
or  on  the  conditions  in  which  these  phenomena  occur  and  their 
symptomatic  value;  that  would  lead  us  into  lengthy  discussions 
which  have  nothing  special  to  do  with  the  female  urinary  system. 

3,  Examination  of  the  Urethra. — To  do  this  examination  we 
commence  by  placing  our  patient  in  such  a  position  so  as  to  use  a 
speculum. 

(a)  First,  inspect  the  meatus  by  separating  carefully  the  labia 
majora  and  minora,  and  thus  enabling  us  to  see  any  lesions  of 
the  mucous  membrane  and  swelling  or  redness.  We  sometimes 
find  a  reddish  little  tumor  which  is  inserted  immediately  behind 
the  meatus;  it  is  a  urethral  polyp  which  explains  symptoms  of 
hematuria. 

It  is  rare  to  find  that  the  urethral  mucous  membrane  forms 
a  hernia  around  the  circumference  of  the  meatus ;  generally  it  is 
a  question  of  prolapse  of  the  mucous  membrane. 

At  other  times  we  find  a  hard  circular  thickening  of  the  mea- 
tus which  indicates  a  malignant  neoplasm  of  the  urethra. 

Finally,  we  may  sometimes  discover  that  the  urethral  orifice  is 
extremely  dilated  without  any  other  sign  of  inflammation;  we 
may  then  conclude  that  the  woman  utilizes  her  urethra  for  other 
uses  than  the  evacuation  of  urine,  and  these  cases  are  not  so  rare 
as  one  would  at  first  suppose. 

American  gynecologists  insist  on  the  necessity  of  always  find- 


EXAMINATION  OF  THE  URETHRA 


473 


ing  out  apart  from  urethritis,  the  state  of  the  canals  called 
Skene's  glands,  which  may  be  easily  seen  by  separating  the  mea- 
tus  with  two  hair-pins  bent  at  right  angles.  Kelly  advises  this 
(Fig.  365). 

(6)  Then  examine  the  canal  of  the  urethra.  Here  again  simple 
inspection  gives, 'in  some  cases,  important  help  in  our  diagnosis, 
as,  for  example,  in  certain  cases  there  exists  a  certain  degree  of 


FIG.  365.— Skene's  glands  (Kelly). 

prolapse  of  the  urethro-vaginal  wall  or  urethrocele.  It  is  easy  to 
recognize  by  examining  the  anterior  wrall  of  the  vagina,  what 
corresponds  to  the  urethra  and  what  to  the  bladder.  The 
urethral  portion,  bulging  like  the  "back  of  an  ass,"  has  regular 
folds  and  is  separated  from  the  more  spread  out  vesical  portion 
by  a  constant  transverse  furrow. 

In  a  general  way,  simple  inspection  is  always  insufficient  to 
diagnose  the  diseases  of  the  urethra;  we  must  have  recourse  to 
other  means,  and  above  all  to  palpation.  The  index-finger 
being  introduced  into  the  vagina,  the  palmar  face  is  applied  to 
the  inferior  wall  of  the  urethra,  and  may  cause  a  drop  of  pus  to 
appear  at  the  orifice  of  the  meatus.  We  thus  examine  the  ure- 
thral secretions  and  find  out,  at  the  same  time,  the  changes  in 


474        CHEMICAL   EXAMINATION   OF   THE    URINARY   APPARATUS 

the  canal,  which  may  be  thickened,  tense,  and  painful  as  in 
the  inflammatory  condition,  or,  on  the  contrary,  hard  with  the 
sensation  of  a  rigid  cord,  and  nodular  as  in  neoplasms.  Finally, 
in  certain  cases  we  find  either  resistance  or  fluctuation,  denoting 
a  sub-urethral  abscess. 

This  external  palpation  of  the  canal  having  been  done,  we 
do  an  exploratory  catheterization  with  a  speculum  and  mandrin 


FIG.  366. — Examination  of  vaginal  secretions. 

which  is  gently  introduced  into  the  bladder.  We  can  thus  find 
out  the  degree  of  sensibility  of  the  canal  and  its  dimensions. 
(d)  The  examination  with  the  urethroscope  will  be  often  very 
useful.  In  order  to  do  it  we  take  a  metallic  tube  of  8  to  10  mm. 
diameter,  furnished  with  a  mandrin  to  prevent  injuring  the 
urethral  mucous  membrane  during  introduction  of  the  instru- 
ment. It  is  introduced  just  into  the  bladder ;  then,  having  with- 
drawn the  mandrin,  it  is  gradually  drawn  out  toward  the  meatus, 
while  a  light  is  thrown  on  the  scene  of  operation  from  a  mirror. 


EXAMINATION   OF  THE   BLADDER  475 

We  can  thus  see  the  neck  of  the  bladder,  then  the  whole  of  the 
urethra,  which  at  first  looks  like  a  flattened  out  tube,  then  has 
the  aspect  of  a  transverse  split,  and  finally  that  of  a  vertical 
split  at  the  level  of  the  meatus.  We  may  thus  distinguish 
everywhere,  on  the  urethral  m'ucous  membrane  vegetations, 
ulcerations,  and  the  orifices  of  the  glands  of  the  urethra. 


FIG.  367. — Urethroscope. 

4.  Examination  of  the  Bladder. — (a)  This  is  first  done  by 
abdominal  palpation;  in  certain  cases  of  vesical  retention  the 
bladder  takes  the  form  of  a  tumor  projecting  into  the  abdomen, 
a  variety  of  tumor  which  we  must  always 'think  of  when  we  are 
examining  a  rounded  and  fluctuating  mass  situated  above  the 
pubis.  Before  doing  an  examination  it  is  better  to  catheterize 
the  bladder.  Abdominal  palpation  enables  us  to  study  the  state 
of  the  sensibility  of  the  bladder,  and  to  find  out  the  seat  of  pain 
on  pressure.  In  pressing  on  the  bladder  gently  and  slowly  we 
may  sometimes  reawaken  pain;  by  brusquely  raising  the  hand 
from  the  abdominal  wall  we  may  also  provoke  pain  if  there  is  an 
inflammatory  lesion. 

(b)  The  vaginal  examination  permits  us  to  find  out,  in  certain 
cases,  the  existence  of  thickening  induration  tumors,  and  also  pain 
in  the  interior  wall  of  the  bladder  if  it  is  combined  with  abdominal 
palpation. 

This  bimanual  palpation  is  an  excellent  means  of  exploration 
of  the  bladder,  and  above  all,  if  one,  as  a  preliminary,  places  the 
patient  in  the  Trendelenburg  position. 

(c)  Then  place  a  speculum  against  the  fourchette,  so  as  to 
depress  it,  and  we  may  examine  the  anterior  vaginal  wall  and 
find  out  if  there  is  any  prolapse  of  the  vesico-vaginal  wall  (cysto- 
cele)  or  vesico-vaginal  fistulas. 

(d)  To  do  catheterization  with  a  speculum  and  mandrin,   we 


476        CHEMICAL   EXAMINATION    OF   THE   URINARY   APPARATUS 

can  determine  the  depth  of  the  bladder  and  the  sensibility  of 
its  posterior  wall;  in  the  normal  state  no  pain  should  be  pro- 
duced; if  there  is  any  sensibility,^  it  is  the  bladder  that  is  inflamed. 

(e)  Afterward  take  a  catheter  and  introduce  it  into  the  bladder 
and  evacuate  it.  Having  done  this,  inject  a  solution  of  Juke- 
warm  boric  acid  slowly  and  gradually  and  continue  until  the 
patient  feels  inclined  to  micturate. 

If  the  bladder  is  healthy,  we  can  easily  introduce  150  to  200 
cm.  cubes  without  producing  the  least  sensation.  If,  on  the  con- 
trary, the  patient  resents  the  introduction  of  25,  30  or  60  c.c., 
this  shows  that  the  physiological  capacity  of  the  bladder  is 
diminished. 

Finally,  cystoscopy  enables  us  to  form  a  complete  knowledge  of 
the  vesical  mucous  membrane.  This  examination,  which  is 
generally  done  in  men  with  a  prismatic  cystoscope,1  may  be  done 
in  a  woman  with  a  simple  urethroscope.  In  order  to  distend  the 
bladder  it  suffices  to  raise  the  pelvic  region  strongly,  so  that  the 
contents  of  the  abdomen  fall  toward  the  diaphragm ;  the  air  enters 
into  the  urinary  reservoir  as  soon  as  the  urethroscope  is  in  com- 
munication with  the  atmosphere.  American  surgeons  place  the 
patient  in  the  genu-pectoral  position,  with  the  chest  in  contact 
with  the  table,  slightly  arching  the  back,  taking  the  precaution 
to  remove  anything  tight  which  might  compress  the  upper  part 
of  the  abdomen  (Fig.  368). 

We  may  also,  as  we  have  said,  place  the  patient  in  the  Tren- 
delenburg  position,  on  an  inclined  plane,  with  the  shoulders 
resting  against  shoulder  pieces  (Fig.  369). 

After  cocainizing  the  urethra,  if  the  rneatus  is  not  1  c.c.  wide, 
it  is  dilated  with  Kelly's  conical  dilator  or  with  Hegar's  bougies. 
Introduce  the  speculum  in  the  direction  of  the  urethra,  inclining 
it  at  first  a  little  toward  the  sacrum  and  then  turning  round  the 
symphysis;  as  soon  as  the  mandrin  is  drawn  out,  the  bladder 
balloons  with  air. 

Once  the  bladder  is  filled  and  the  urethroscope  in  place,  we 
light  up  the  bladder  with  a  frontal  mirror  and  lamp,  which  is 
thoroughly  examined. 

If  it  is  healthy,  the  mucous  membrane  appears  smooth  and 

1  See  Hartmann,  Surgery  of  the  Genito-urinary  System  in  Man.    Paris,  G.  Steinheil, 
1904. 


EXAMINATION  OF  THE   BLADDER 


477 


FIG.  368. — Dilatation  of  the  bladder,  vagina  and  rectum  in  the  genu-pectoral  position 

(after  Kelly). 


FIG.  369. — Examination  of  the  bladder  with  patient  in  the  Trendelenburg  position. 


478        CHEMICAL   EXAMINATION   OF   THE    URINARY   APPARATUS 

pale  or  with  some  vessels  showing.  Examination  with  Nitze's 
cystoscope  always  gives  the  impression  of  larger  and  redder  vessels 
than  with  the  direct  urethroscopic  examination,  because  with  this 
latter  means  of  exploration,  the  bladder  becomes  less  congested 


FIG.  370. — Kelly's  conical  dilator. 

by  reason  of  the  elevated  position  of  the  pelvis.  With  the 
urethroscopic  tube,  we  inspect  successively  the  trigone  and 
different  segments  of  the  bladder. 

5.  Examination   of   the   Ureters.— (a)  Abdominal  palpation 
enables  us  to  find  out  any  pain  along  the  course  of  the  ureter. 


FIG.  371. — Relations  of  the  ureters  with  the  vagina  (Dartigues). 

(6)  Vaginal  examination  gives  more  precise  indications. 
When  the  finger  is  introduced  into  the  vagina  by  following  the 
median  line  as  far  as  the  cervix  uteri,  one  cannot  feel  the  ureter, 
but  if  the  finger  being  in  the  anterior  f  ornix,  is  turned  laterally  we 
feel  anterior  to  the  cervix,  in  describing  an  arched  course  around 
the  anterior  fornix  and  stopping  a  little  distance  from  the  median 
line,  a  little  hard  cord,  the  ureter.  Normally  it  is  hard  to  dis- 


EXAMINATION  OF  THE  KIDNEYS  479 

cover.  If  one  finds  a  thick  and  hard  cord,  during  vaginal  exam- 
ination which  is  outlined  against  the  vaginal  vault,  and  situated 
outside  the  median  line,  we  may  be  sure  that  we  have  to  deal  with 
a  diseased  ureter. 

6.  Examination  of  the  Kidneys. — Examination  of  the  kid- 
neys reveals  nothing  in  particular  in  a  woman;  bimanual  palpa- 
tion is  generally  carried  out  as  in  man.1 

In  order  to  appreciate  their  functional  value,  we  may  have 
recourse  either  to  urethral  catheterization,  or  to  intravesical 
separation,  so  simple  in  its  technic  that  any  doctor  may  practice 
it  without  any  preliminary  education  with  the  instrument  con- 
structed by  M.  Gentile  for  our  old  assistant,  Dr.  Luys. 

This  apparatus  is  introduced  closed  into  the  bladder;  make 
the  india-rubber  septum  bulge,  and  applying  the  instrument 
against  the  inferior  wall  of  the  bladder,  we  are  able  to  make  a 
recess,  the  urine  from  each  kidney  accumulating  on  each  side 
of  the  septum,  and  afterward  evacuated  externally  by  the  two 
tubes. 

The  urine  flows  naturally  and  every  20  or  25  seconds  we  may 
see  drops  issuing  which  correspond  to  the  intermittent  ejacula- 
tion of  the  ureters. 

This  apparatus  has  given  me  excellent  results. 

Catheterization  of  the  ureter,  which  one  is  able  to  do  with  the 
prismatic  cystoscope  in  man,  is  most  often  done  in  woman  directly 
through  a  urethroscopic  tube.  Its  technic  has  been  fully  worked 
out  by  the  American  surgeons,  Kelly  in  particular. 

In  order  to  avoid  dilatation  of  the  bladder  when  the  air  enters, 
it  is  recommended  to  introduce  the  urethroscopic  tube  to  partly 
open  the  vagina  in  such  a  way  that  it  fills  with  air,  which  presses 
back  the  vesico- vaginal  septum  toward  the  abdominal  wall. 
In  these  conditions  if  one  introduces  the  urethroscope,  this 
septum  is  raised  a  little  toward  the  vagina,  but  rarely  above  the 
horizontal,  and  thus  its  ureteral  orifices  are  brought  on  a  level 
with  the  speculum. 

In  order  to  see  them,  draw  back  the  urethroscopic  tube  until 
the  mucous  membrane  of  the  deep  orifice  of  the  urethra  appears 
on  a  line  with  its  internal  extremity.  The  handle  of  the  instru- 
ment is  then  raised,  and  the  speculum  directly  pushed  into  the 

1  See  Hartmann,  Surgery  of  the  Genito-urinary  Organs  in  Man. 


480        CHEMICAL   EXAMINATION   OF  THE    URINARY   APPARATUS 

bladder  to  a  depth  of  three  cm.  Lowering  this  handle  in  such 
a  way  as  to  bring  the  end  of  the  urethroscope  on  the  same  plane 
as  the  base  of  the  bladder,  we  progressively  incline  the  instrument 


FIG.  372. — Luys'  separator  in  position. 

laterally  until  one  sees  the  ureteral  orifice,  which  ordinarily 
appears  when  one  has  traversed  an  arc  of  15°  to  30°  about  the 
median  line. 

In  some  cases,  following  an  inflammation  of  the  vesical 
mucous  membrane,  the  ureteral  orifice  does  not  appear  clearly. 
We  are  then  guided  by  the  discharge  of  urine  at  its  level  and  we 
may  insert  a  fine  metallic  stilette  in  order  to  find  it. 


CHAPTER  II. 

SURGERY  OF  THE  URETHRA. 

Summary. — Operations  on  the  urethra  (catheterization,  dilatation,  inter- 
nal urethrotomy,  external  urethrotomy,  urethrectomy,  operations  for  incon- 
tinence of  urine). — Treatment  of  diseases  of  the  urethra  (wound,  foreign 
bodies,  calculi,  inflammation,  suburethral  abscesses,  urethrocele,  prolapse  of 
mucous  membrane,  tumors). 

1.  Operations  on  the  Urethra. 

Catheterization. — Catheterization  is  one  of  the  simplest  opera- 
tions, owing  to  the  shortness  and  rectilinear  direction  of  the 
female  canal.  The  only  precaution  to  take  is  only  to  act  with 
the  strictest  antisepsis.  We  must  only  use  sterilized  instru- 
ments. Clean  the  meatus  thoroughly  and  only  do  the  operation 
under  visual  control. 

The  meatus  is  normally  found  above  the  tubercle  which  limits 
anteriorly  the  anterior  column  of  the  vagina.  Above  this  land- 
mark is  the  constant  position  of  the  external  orifice  of  the  urethra. 
It  is  sufficient  in  order  to  do  the  catheterization  to  engage  the 
end  of  the  sound  well  within  it,  then  to  slightly  lower  its  extremity 
and  at  the  same  time  push  it  forward.  Before  the  extremity 
of  the  sound  penetrates  the  bladder  it  is  well  to  place  one's  thumb 
over  its  extremity  in  order  to  prevent  the  urine  from  flowing 
anywhere  except  into  the  destined  receptacle. 

Some  difficulties  wrhich  are  exceptionally  met  writh  are  con- 
nected either  with  the  meatus  being  taken  for  peri-urethra] 
excrescences  or  by  the  bent  back  protuberance  of  the  anterior 
tubercle,  which  lies  normally  below  this  orifice,  or  that  the  canal 
is  deviated  anteriorly  due  to  pregnancy  or  a  uterine  tumor,  or 
backward  due  to  a  dilatation  of  its  interior  wall  from  a  urethrocele. 
If  we  bear  these  in  mind  we  will  easily  avoid  them. 

Dilatation  of  the  Urethra. — The  meatus  is  the  least  dilatable 
portion  of  the  urethra;  also  when  it  is  small  and  rigid,  it  is  well 

31  481 


482 


SURGERY   OF   THE   URETHRA 


before  commencing  to  do  the  dilatation  to  make  some  small 
lateral  incisions. 

If  we  wish  to  obtain  a  moderate  dilatation,  for  example,  in  a 
case  where  we  wish  to  do  a  cystoscopy,  or  a  separation  of  urine,  it 
is  then  sufficient  to  pass  some  Hegar's  bougies  or  Beniques' 
straight  dilators  into  the  urethra. 


FIG.  373.— Hegar's  bougies  with  double  graduation. 

If  one  proposes  to  do  a  free  dilatation,  we  may  use  Hegar's 
bougies  and  gradually  increasing  the  caliber. 

In  order  to  dilate  the  urethra  and  vesical  neck,  we  may  use 
special  instruments  such  as  Tripier's  hollow  dilator,  Guyon- 
Duplay's1  dilators  with  accompanying  mandrins,  or  Kelly's 


FIG.  374. — Tripier's  hollow  dilator 


conical  dilator,  etc.  The  important  point  is  to  act  with  caution, 
never  to  dilate  brusquely,  and  not  to  go  beyond  a  caliber  of  20 
mm.  diameter.  We  will  thus  avoid  the  somewhat  rare  complica- 
tions such  as  rupture,  tearing  of  the  canal,  hemorrhage,  infiltra- 
tion and  incontinence  of  urine. 


FIG.  375. — Pasteau's  straight  urethrotome. 

These  wide  dilatations  have  been  advised  in  the  treatment  of 
certain  cases  of  painful  cystitis.  They  are  above  all  useful  as 
preliminary  operation  to  a  digital  exploration,  to  the  extraction  of 
a  foreign  body,  or  a  curettage  of  the  bladder. 

1  Hartmann,  Painful  Cystitis  and  Its  Treatment.     Th.  de  Paris,  G.  Steinheil,  1887. 


OPERATIONS  ON  THE  UTERUS  483 

Internal  Urethrotomy. — Internal  urethrotomy  has  only  rare 
indications  in  women.  It  is  carried  out  on  the  superior  wall 
with  Maisonneuve's  urethrotome,  or  better  with  a  straight 
urethrotome.  The  operation  and  following  treatment  have  the 
same  consideration  as  in  the  case  of  man.1 

External  Urethrotomy. — This  is  very  simply  done  in  woman 
by  directly  incising  the  urethro-vaginal  septum.  It  may  also  be 
done  as  Legueu  advises  by  the  sub-symphyseal  route,,  which  enables 
us  to  surely  avoid  a  fistula. 

After  having  exposed  the  vulvar  vestibule  by  separating  the 
labia  minora,  we  make  above  the  meatus  and  between  this  and 
the  clitoris  a  curved  incision  with  its  concavity  inferior.  With 
the  bistoury  scissors  or  finger  we  separate  the  urethra  from  the 
symphysis,  stopping  laterally  when  wre  reach  the  corpora  caver- 
nosa,  which  we  must  save,  cutting  through  and  tying,  if  necessary, 
the  vessels  which  go  to  the  urethra.  This  is  incised  on  a  line 
with  its  superior  face  on  a  cannulated  sound. 

Once  the  operation  is  finished,  we  suture  the  urethra  after 
placing  a  sound  in  position  and  closing  up  the  sub-symphyseal 
wound  by  buried  catguts,  which  lift  up  the  meatus  toward  the 
clitoris  and  give  to  the  canal  its  normal  curve.  Some  superficial 
silkworm-guts  unite  the  borders  of  the  vestibular  incision. 

Urethrectomy. — Legueu  and  Duval  recommend  the  sub- 
symphyseal  route  and  preliminary  incision  of  the  urethra  on  its 
superior  wall  so  as  to  gauge  from  the  commencement  the  extent 
of  the  parts  to  be  removed.  Having  done  this,  free  the  interior 
wall  of  the  canal  to  the  extent  of  the  future  section.  Before 
doing  this,  we  insert  two  paraurethral  sutures,  one  on  each  side, 
in  the  canal  in  order  to  prevent  its  retraction  toward  the  bladder. 
The  urethra  is  cut  across  in  front  of  these  sutures  and  fixed  in  the 
posterior  angle  of  the  vaginal  wall.  This  is  reconstituted  by  suture 
in  front  of  the  new  meatus* 

When  it  is  necessary  to  extirpate  all  the  urethra,  the  view 
obtained  by  the  sub-symphyseal  incision  is  not  sufficient ;  Zweifel 
combines  it  with  symphysiotomy.  Mac  Gill  commences  by  a 
suprapubic  incision,  then  lifts  out  .the  tumor  by  the  vagina, 

1  See  Hartmann,  Surgery  of  the  Genito-urinary  Organs  in  Man.  Paris,  G.  Steinheil, 
1904. 


4S4 


SURGERY   OF   THE    URETHRA 


which  an  assistant  presses  back  below  with  two  fingers  intro- 
duced into  the  bladder. 

The  functional  result  of  the  partial  extirpations  is  excellent; 
on  the  contrary,  total  removal,  with  incision  of  the  vesical 
sphincter,  is  followed  by  incontinence.  Also  certain  surgeons 
completely  close  up  the  urethro-vesical  wound  and  establish 
a  hypogastric  meatus,  on  which  a  urinal  may  easily  be  applied 
(Mac  Gill,  Zweifel,  Battle). 


FIG.  376. — Trace  of  the  incision  for  urethrectomy. 


These  urethrectomies  have  been  done  for  neoplasms;1  it  is 
necessary  generally  to  do  at  the  same  time  an  extirpation  of 
inguinal  ganglions. 

Operations  for  Incontinence  of  Urine. — A  great  number  of 
operations  have  been  advised  for  incontinence  of  urine  of  urethral 
origin.2 

1  We  have  had  occasion  to  do  with  the  success  of  a  durable  resection  of  the  terminal 
portion  of  the  urethra  for  one  case,  up  to  now  quite  unique,  of  tuberculous  structure, 
recalling  by  its  aspect  those  of  constrictions  of  the  same  nature  in  the  rectum.     (Hart- 
mann,  Hypertrophic  Tuberculosis  with  Resulting  Stenosis  of  the  Urethra  in  a  Woman. 
Th.  de  Paris,  G.  Steinheil,  1907,  p.  1.) 

2  Cottard  (H.),  Operative  Treatment  of  Incontinence  of  Urine  in  Women.     Th.  de 
Paris,  G.  Steinheil,  1906-1907,  No.  63. 


OPERATIONS  ON  THE   UTERUS 


485 


Some  wish  to  constrict  the  canal;  we  may  do  this  very  simply 
by  doing  an  anterior  colporrapky,  sub-urethro-vesical,1  reconsti- 
tuting at  the  inferior  part  of  the  urethra  a  solid  column  and  at 
the  same  time  tightening  up  the  periurethral  tissues.  Associated 
with  a  perineorraphy,  the  anterior  variety  suffices  most  often  to 
cure  incomplete  incontinence  of  women  with  prolapse  and 
exaggerated  laxity  of  the  pelvic  tissues. 

Gersuny  has  endeavored  to  obtain  the  same  result  by  doing 
around  the  cervix  a  series  of  injections  of  paraffin.2  With  a 


FIG.  377. — Operation  for  in- 
continence of  urine.  Trace  of 
the  incision. 


FIG.  378.— The  urethra  has 
been  dissected.  A  fold  is 
made  on  its  superior  wall. 


syringe,  the  body  of  which  is  heated  by  a  circulation  of  hot 
water,  he  injects,  after  local  anesthesia,  about  2  c.c.  of  fusible 
paraffin  at  55°  in  the  neighborhood  of  the  cervix,  circumscribing 
this  with  a  series  of  small  masses  of  paraffin. 

Pawlick  made  an  operation  displacing  and  oblongating  the 
urethra;  Duret  and  we  also  construct  the  urethra  and  lift  up  the 
meatus  toward  the  clitoris.  Gersuny  twisted  the  urethra,  after 
dissecting  up.  Pousson  combined  torsion  with  raising  of  the 
meatus.  Fritsch  does  a  sub-pubic  incision,  separates  the  urethra 
and  bladder  from  the  symphysis,  excises  a  long  longitudinal 

1  This  sub-urethral  colporraphy  may  be  .done  by  denudation  or  by  splitting. 

2  Gersuny,  Paraffineinspritzung  bei  Incontinentia  Urinse.     Centr.  Bl.  fur  Gyn.,  1900, 
Stein,  Par.-inj.     Th.  de  Paris,  Stuttgart,  1904. 


486  SURGERY  OF  THE   URETHRA 

band  from  the  superior  wall  of  the  canal  and  cervix,  and  then 
unites  the  urethra]  wound  with  a  continuous  suture. 

The  procedure  which  appears  best  to  us  is  that  described  by 
Albarran;  it  is  a  rational  combination  of  several  operations  that 
are  done  anteriorly. 

A  longitudinal  incision  commences  at  the  clitoris  and  encircles 
the  meatus.  A  triangular  incision  is  made  below  this  as  in 
Fig.  377.  The  two  triangular  flaps  having  been  dissected  up, 
the  urethra  appears  to  form  the  base  of  the  wound.  This  is 


FIG.  379. — The  folded  urethra  has  been  turned  in  through  a  half  circle  and  then  lifted 

up  below  the  clitoris. 

dissected  up  gradually,  preserving  its  muscular  tunic  and  sepa- 
rating below  the  vaginal  wall  up  to  within  a  little  of  the  neck  of  the 
bladder.  It  is  then  easy  to  draw  down  the  canal  and  to  make  on 
its  superior  wall  a  longitudinal  fold  which  constricts  it  (Fig.  378). 

The  urethra  having  been  constricted  by  a  longitudinal 
superior  fold  is  turned  in  for  one-half  a  circumference  and  drawn 
upward;  the  meatus  is  fixed  immediately  below  the  clitoris  and 
then  the  vaginal  wound  is  sutured  (Fig.  379). 

In  case  of  rebellious  incontinence,  Hofmeier1  after  an  anterior 
colpotomy,  lowers  the  uterus  into  the  thickness  of  the  urethro- 
vesico- vaginal  septum  so  that  we  thus  make  a  sort  of  sub-urethral 

1  Hofmeier,  Ann.  de  gynec.,  Paris,  1906,  p.  701. 


TREATMENT  OF  DISEASES  OF  THE  URETHRA  487 

plug  which  compresses  the  canal.     We  have  had  recourse  to  the 
same  procedure  and  we  have  found  it  very  useful.1 

2.  Treatment  of  Diseases  of  the  Urethra. 

Wounds  of  the  Urethra. — The  recent  wounds  are  treated  by 
immediate  suture  and  the  ancient  by  denudation  and  suture. 

Foreign  Bodies  and  Calculi. — If  the  foreign  body  or  the 
calculus  is  near  the  meatus,  visible  and  easily  accessible,  it  is 
sufficient  to  dilate  the  meatus  of  the  urethra  in  order  to  make 
the  calculus  come  out  by  pressure  from  behind  forward.  If  it 
is  further  back,  it  is  extracted  with  a  curette  or  better  with  a 
pair  of  forceps  introduced  through  the  urethroscope,  and  with- 
drawing at  the  same  time  the  calculus,  forceps  and  urethroscopic 
tube.  If  it  is  impossible  to  withdraw  the  calculus,  we  must  do 
an  external  urethrotomy.  In  a  certain  number  of  cases  the 
calculus  is  lodged  in  a  diverticulum  of  the  urethra ;  it  is  neces- 
sary, by  a  vaginal  incision,  to  remove  the  calculus  and  to  excise 
the  pocket,  terminating  with  a  suture  in  two  planes. 

Urethritis. — At  the  commencement  if  there  is  an  acute  inflam- 
mation not  only  of  the  urethral,  but  also  of  all  the  vulvar  region, 
we  must  give  hot  baths,  vaginal  injections  of  permanganate, 
applications  of  compresses  soaked  in  the  same  solution,  and 
prescribe  abundant  drinks.  In  some  few  days  we  give  balsamic 
products,  and  if  necessary,  we  have  recourse  to  lavage  of  the 
urethra.  These  may  be  done  with  or  without  sound.  If  we 
use  a  sound,  as  the  urethra  is  short,  we  should  use  straight 
sounds,  with  a  back  flow,  which  are  introduced  as  far  as  the 
cervix ;  the  liquid  comes  back  to  the  meatus,  washing  the  canal 
from  behind  forward  (Fig.  380). 


FIG.  380. — Cannula  with  recurrent  flow. 

Often  reinoculation  occurs  through  the  existence  of  a  series 
of  other  infectious  loculi  in  the  vagina,  the  uterine  cervix, 
Bartholin's  glands  and  above  all  in  the  little  pockets  described 
by  Skene  below  the  meatus. 

1  For  the  technic  of  this  operation  see  Colpoceliotomy. 


488  SURGERY   OF   THE   URETHRA 

We  must  wash  out  these  glands  in  a  special  manner,  injecting 
into  them,  through  fine  cannulas,  some  drops  of  a  solution  of 
potassium  permanganate,  1  to  300,  emptying  this  by  pressure 
and  then  re-commencing  the  injection.  Carbolic  acid  in  con- 
centrated solution  and  nitrate  of  silver  have  been  recommended. 
In  order  to  put  an  end  to  the  suppuration  of  these  diverticula  it 
has  been  advised  to  split  the  wall  of  mucous  membrane  which 


FIG.  381. — Sterilizable  syringe. 


separates  them  from  the  canal  or  to  destroy  them  by  insinuating 
into  them  the  fine  point  of  a  galvano-cautery. 

At  a  later  period  we  have  advised  lavage  of  the  urethra  with 
a  solution  of  oxycyanide  of  mercury  and  applications  to  the  canal 
with  pure  ichthyol. 

It  is  important  to  continue  the  treatment  during  the  duration 
of  menstruation  and  to  pursue  the  infection  wherever  it  is 
localized  and  not  confining  oneself  to  the  urethra,  jas  rauto- 
infection  is  very  frequent. 


FIG.  382.  FIG.  383. 

Fine  cannulas  for  injections  of  the  para-urethral  canals. 

A  variety  of  urethritis,  observed  above  all  in  women  and 
rebellious  to  ordinary  treatment,  is  proliferating  urethritis,  which 
may  cause  small  urethrorrhagia  and  sometimes  partial  retention 
of  urine.  If  the  lesions  are  limited  to  the  terminal  part  of  the 
canal,  we  may  obtain  cure  by  doing  a  partial  resection  of  the 
urethra;  if  they  extend  as  far  as  the  neck  of  the  bladder,  the 
resection  of  the  urethra  is  not  to  be  considered  as  it  would  lead 
to  incontinence ;  Legueu  advocates,  in  such  a  case,  to  destroy  the 
vegetations  after  having  practised  a  sub-symphyseal  external 
urethrotomy.  We  have  found  simple  destruction  with  the 
galvano-cautery  quite  useful,  to  be  done  in  several  sittings, 
advancing  little  by  little  into  the  depths,  after  local  anesthesia 
and  through  the  urethroscopic  tube. 


TREATMENT  OF  DISEASES  OF  THE  URETHRA  489 

Sclerous  urethritis  is  exceptional;  it  is  treated  with  massage 
and  dilatation  done  with  Beniques  bougies  and  pushed  as  far 
as  Nos.  55  and  60.  If  it  fails,  we  may  have  recourse  to  internal 
urethrotomy  or  even  to  external  urethrotomy  by  the  sub-symphy- 
seal  route,  removing  the  callosities  and  leaving  without  union  the 
superior  wall  of  mucous  membrane  so  as  to  thus  add  a  piece 
to  the  urethra  (Legueu). 

Suburethral  Abscess.— Suburethral  abscesses,1  which  often 
open  into  the  urethra,  may  be  followed  by  urethro-vestibular  or 
urethro- vaginal  fistulas;  they  are  treated  by  a  broad  vaginal 
incision,  curettage  and  tamponing.  If  the  intervention  is 
followed  by  a  fistula,  it  is  closed  secondarily  with  a  little  operation. 

Urethrocele. — Sometimes  confounded  with  cystocele,  urethro- 
cele  is  easily  distinguished  by  the  fact  that  the  seat  of  tumefaction 
is  at  the  level  of  the  urethra,  in  front  of  a  transverse  furrow, 
always  visible  on  the  vaginal  wall  and  corresponding  deeply  to 
the  neck  of  the  bladder.  The  introduction  of  curved  sounds  into 
the  canal  shows  that  it  is  a  pocket  corresponding  with  the 
urethra. 

To  operate  split  the  whole  thickness  of  the  pocket  on  a 
cannulated  sound  and  excise  a  melon-shaped  area  from  its 
inferior  wall  and  afterward  suture  the  parts  together. 

Prolapse  of  the  Urethral  Mucous  Membrane. — Treatment  con- 
sists in  excision  followed  by  suture,  splitting  the  prolapse  in  the 
middle  line  antero-posteriorly  we  insert  at  each  extremity  two 
catguts  which  unite  the  mucous  membrane  of  the  urethra  to  that 
of  the  external  face  of  the  meatus ;  then  excise  successively  each  of 
the  halves,  right  and  left,  suturing  the  mucous  membrane  as  the 
section  advances,  doing  in  all  points  an  operation  similar  to  that 
of  Whitehead  for  hemorrhoidal  prolapse  of  the  anus. 

In  infants  Stoeckel  after  drawing  down  the  prolapse  ties  it 
with  a  fine  silk  on  a  Nelaton  sound;  a  cure  is  rapidly  obtained 
after  necrosis  and  detachment  of  the  strangled  mucous  cylinder. 

Tumors. — Small  excrescences  (mucous  polyps,  papillary  angio- 
mata,  caruncles)  which  are  observed  often  enough  at  the  level 
of  the  meatus  and  are -excised  with  curved  scissors;  then  their 
surface  of  implantation  is  cauterized  with  nitrate  of  silver;  if  it 
is  large  enough  insert  a  catgut  suture.  Fibromata  and  myomata 

1  J.  Baury,  Periureteral  Myomata  in  Woman.     Th.  de  Paris,  1895-1896,  No.  103. 


490  SURGERY  OF  THE  URETHRA 

are  extirpated  by  enucleation.  In  presence  of  cancer  of  the 
urethra1  we  should  do  urethrectomy.  A  particular  point  merits 
mention,  i.e.,  the  possible  existence  of  periurethral  malignant 
tumors.  In  such  a  case  spare  the  urethra  without  great  incon- 
venience from  the  point  of  view  of  recurrence.  In  all  cases  we 
should  remove  as  well  as  the  tumor  the  inguinal  glands. 

1  Percy,  Primary  Carcinoma  of  the  Urethra  in  the  Female.  Am.  J.  of  Obstet.,  New 
York,  April,  1903,  T.  I,  p.  457.  Yasuzo  Karaki,  Ueber  prim.  Karz.  der  Weib.  Harnrohre. 
Zeilsch.  f.  Geb.  u.  Gyn.,  1907,  Stuttgart,  T.  LXI,  p.  151. 


CHAPTER  III. 

SURGERY  OF  THE  BLADDER. 

Summary. — Operations  on  the  bladder  (vestibular  section,  colpocystot- 
pmy,  colpocystostomy,  lithotrity,  curettage). — Treatment  of  diseases  of  the 
bladder  (foreign  bodies  and  calculi,  cystitis  and  prolapse  of  the  vesical 
mucous  membrane). 

1.  Operations  on  the  Bladder. 

Cystotomy. — The  bladder  may  be  opened  in  women  in  various 
ways:  above  the  pubis,  suprapubic  cystotomy;  below  the  pubis  it 
is  the  old  vestibular  section  of  Lisfranc;  by  the  vagina  it  is 
colpocystotomy. 

Perineal  Section. 

Vestibular  section,  suggested  and  practised  in  1823,  has  been 
taken  up  again  latterly  by  Legueu  under  the  name  of  sub- 
symphyseal  section.  The  first  stages  of  the  operation  are 
identical  with  those  of  subsymphyseal  external  urethrotomy. 

The  superior  face  of  the  urethra  being  freed,  the  finger 
separates  the  retro-pubic  fibrous  tissues,  aided  by  a  scalpel,  the 
point  of  which  is  directed  upward  so  as  not  to  injure  the  canal. 
As  soon  as  one  has  reached  the  level  of  the  bladder,  the  separation 
is  very  easy. 

We  may  then  incise  the  bladder  or  cervix.  In  principle  it  is 
better  to  respect  the  latter.  We  make  a  vertical  incision  in  its 
wall  between  the  two  ascending  veins  of  the  anterior  face  of  the 
bladder  and  then  place  on  each  lip  a  suspensory  suture  so  as  to 
be  able  to  explore  the  interior  of  the  urinary  reservoir. 

When  the  operation  is  finished,  close  the  vesical  wound  in  one 
or  two  planes;  suture  the  soft  parts  of  the  vestibule  with  the  aid 
of  interrupted  catgut  sutures,  leaving  a  little  median  drain  which 
is  soon  removed.  A  catheter  is  left  in. 

491 


492 


SURGERY   OF   THE    BLADDER 


FIG.  384. — Catheter  for  vaginal 
section  (Hartmann). 


FIG.  385. — Colpocystotomy.  The  catheter  makes 
the  vesico-vaginal  septum  bulge.  The  incision  com- 
mences anteriorly  a  little  behind  the  transverse  groove 
which  indicates  the  situation  of  the  neck 
bladder. 


OPERATIONS  ON  THE   BLADDER  493 

This  procedure  is  particularly  applicable  to  cases  where  the 
vaginal  route  cannot  be  used  because  of  the  hymen. 

Colpo-cystotomy. 

The  patient  is  placed  in  the  usual  position  for  vagino-perineal 
operations ;  the  bladder  is  washed  out,  then  moderately  distended 
by  the  injection  of  150  to  200  c.c.  of  lukewarm  boracic  acid. 

An  assistant  draws  down  the  posterior  wall  of  the  vagina  with 
speculum ;  with  an  ordinary  catheter  or  better  with  a  special  coude 
catheter,  which  is  grooved  for  a  distance  of  about  4  cm.  (1  1/2 
inches)  along  its  intravesical  convex  portion  (Fig.  384).  This 
catheter  should  be  maintained  in  the  median  plane  so  as  to  save 
the  ureters.  The  surgeon,  with  his  index-finger  against  the 
groove,  punctures  the  vagina  about  1  cm.  behind  the  neck  of  the 
bladder;  by  aid  of  the  grooving,  he  is  enabled  to  push  in  the 
bistoury  from  1  1/2  to  2  cm.  and  to  incise  the  whole  thickness 
of  the  vesico- vaginal  septum  by  a  sort  of  transfixion;  he  is  thus 
certain  of  avoiding  any  slipping  and  of  being  able  to  make  a 
section  of  the  vesical  mucous  membrane  corresponding  very 
exactly  to  that  of  the  vaginal  mucous  membrane. 

The  intra-vesical  operations  (extraction  of  a  calculus,  of  a 
foreign  body,  etc.)  having  been  done,  we  suture  in  two  planes  the 
incision  in  the  septum  and  then  place  in  a  catheter,  which  is 
left  in  for  10  to  12  days. 

Rochet,  fearing  the  consecutive  formation  of  a  fistula,  makes  about  1  cm. 
behind  the  meatus  a  transverse  incision  of  3  to  5  cm.  about,  which  only 
goes  through  the  vaginal  mucous  membrane.  Then  he  separates  with  the 
grooved  sound  or  with  blunt  scissors  the  vaginal  mucous  membrane  of  the 
urethra  and  bladder;  he  then  incises  the  latter. 

Kelly  places  the  patient  in  the  genu-pectoral  position,  punctures  the 
bladder  with  a  conde  bent  at  right  angles,  about  1  1/2  cm.  from  the  cervix 
uteri  and  then  brings  the  bistoury  into  the  median  line  in  the  direction  of  the 
urethra  until  he  judges  the  incision  sufficiently  large. 

Colpocystostomy. — If  we  propose  to  keep  the  incision  in  the 
vesico-vaginal  septum  permanent,  in  order  to  make  a  fistula  in 
the  bladder  as  is  done  in  certain  rebellious  cases  of  chronic 
cystitis,  it  is  well  to  prolong  the  incision  a  fair  distance  backward 


494  SURGERY  OF  THE    BLADDER 

until  we  reach  the  neighborhood  of  the  cervix  uteri  in  order  to 
avoid  persistence  of  a  cul-de-sac  at  this  level  and  then  as  the 
wound  has  a  tendency  to  heal  spontaneously  and  closes  rapidly, 
stitch  the  vesical  mucous  membrane  to  that  of  the  vagina. 

It  is  unfortunately  not  always  possible  because  of  the  friabil- 
ity of  the  mucous  membrane  and  its  adherence  to  the  adjacent 
layers  resulting  from  inflammatory  conditions.  In  such  a  case 
we  must  be  content  with  passing  a  large  drain  into  the  bladder, 
from  the  urethra  to  the  fistula,  uniting  its  two  extremities  with 
a  suture.  After  a  few  days  take  the  drain  out  and  the  fistula  is 
thus  formed.  If  later  it  has  a  tendency  to  contract,  enlarge  it 
with  the  thermo-cautery. 

It  is  well  to  use  boracic  acid  to  wash  out  the  vagina  in  order 
to  prevent  stagnation  of  urine  and  the  formation  of  phosphatic 
concretions.  Although  there  may  be  from  time  to  time  fibrinous 
detritus  obliterating  the  fistula,  we  should  always  make  our  vesical 
injections  with  gentleness.  They  pass  by  the  urethra  and  come 
out  by  the  fistula. 

Lithotrity. — Lithotrity  in  a  woman  is  more  difficult  than  in  a 
man  which  is  due  to  the  absence  of  a  grown  recess  and  to  the  fact 
that  fragments  of  calculi,  instead  of  becoming  united  are  dissem- 
inated over  the  whole  extent  of  the  bladder.  We  should  also 
follow  Guyon's  counsel1  and  create  an  operative  field  by  pressing 
down,  with  the  help  of  the  lithotrite,  the  vesico- vaginal  wall  near 
the  neck.  This  is  done  in  order  to  cause  the  calculus  to  curve 
there.  It  is  then  seized  and  broken  up. 

Curettage  of  the  Bladder. — Curettage  of  the  bladder  has  been 
done  through  the  urethra.2  After  anesthesia  and  washing  out  of 
the  bladder  introduce  a  long  and  sharp  curette  and  then  using 
the  vaginal  finger  as  a  support  we  curette  the  interior  wall  of  the 
bladder.  For  the  remaining  surfaces  of  the  bladder  curettage  is 
always  less  perfect  as  the  wall  recedes  under  the  pressure  of  the 
curette  and  risks  being  perforated.  It  is  important  to  curette 
thoroughly  the  region  of  the  neck  of  the  bladder  and  once  the 
curettage  is  finished,  do  a  free  lavage  of  the  bladder  (1  to  1000 
sublimate)  or  nitrate  of  silver  (1  to  500),  creosote  (1  in  100),  and 
even  pure  tincture  of  iodine.  Pezzer's  large  catheter  is  left  in 

1  Guyon,  Annals  of  gynecology ,  Paris,  1891,  T.  I,  p.  241. 

2  Coursier,  Treatment  of  Rebellious  Cystitis  in  Woman.     Th.  de  Paris,  G.  Steinheil,. 
1894. 


TREATMENT  OF  DISEASES  OF  THE   BLADDER  495 

and  serves  to  instil  each  day,  in  the  morning  nitrate  of  silver 
1  to  50  and  in  the  evening  gomenol  1  in  20. 

2.  Treatment  of  Diseases  of  the  Bladder. 

Foreign  Bodies  and  Calculi. — Foreign  bodies  are  often  fre- 
quently observed  in  the  female  bladder.  In  a  great  number  of 
cases  it  is  possible  to  extract  them  per  mas  naturales.  This 
extraction  is  facilitated  by  using  special  instruments,  such  as  a 
blunt  hook  which  locks. 

It  is  made  by  Collin  and  recommended  for  the  purpose  of 
drawing  hair-pins  out  of  the  bladder,  these  being  the  most 
common  of  foreign  bodies.  It  is  generally  easy  enough  to 
seize  the  pin,  but  often  difficult  to  extract  it.  The  pin  is  intro- 
duced by  its  rounded  end ;  once  in  the  bladder,  it  props  itself  up 


FIG.  386. — Locking  hook. 


by  its  two  points  against  the  neck  of  the  bladder  or  takes  a  trans- 
verse position;  once  having  seized  it,  we  must  draw  it  gently 


FIG.  387. — Needle  seized  with  the  blunt  end,  curved  hook  is  pulled  through  the  urethro- 

•  scopic  tube. 

out.  First  determine  the  situation  and  direction  of  the  foreign 
body  with  the  urethroscopic  tube,  and  then  under  the  visual 
control  bring  it  to  be  in  good  position  and  extract  it. 

If  this  fails,  dilate  the  neck  of  the  bladder  and  with  the  finger 
turn  it  round  and  draw  it  out  with  its  convexity  toward  the  cervix 
and  thus  remove  it  with  the  greatest  facility. 


496  SURGERY   OF   THE    BLADDER 

If  the  foreign  body  is  encrusted  break  up  with  a  lithotrite  the 
phosphatic  incrustations  which  surround  it. 

If  the  foreign  body  cannot  be  extracted  by  the  urethra,  then 
do  one  of  the  vesical  sections,  particularly  colpo-cystotomy,  which 
although  not  to  be  strongly  recommended  for  removal  of  neo- 
plasms, is  excellent  for  the  removal  of  calculi  and  foreign  bodies. 

Cystitis. — The  general  indications  of  treatment  are  the  same  in 
both  sexes.  In  a  woman  with  cystitis  we  should  always  look  for 
any  concomitant  affection  of  the  genital  system  which  may  cause 
and  keep  up  the  inflammation  of  the  bladder.  This  question  of 
relationship  betwreen  the  disease  of  the  genital  and  urinary 
systems  in  women  is  still  badly  known  and  demands  more  study 
to  elucidate  it. 

Prophylactic  treatment  is  very  important ;  we  still  see  too  many 
cystites  following  on  catheterization.  We  should  avoid  useless 
catheterization  and  only  do  it  when  the  bladder  is  felt  distended 
above  the  pubis.  The  important  point  is  to  have  the  strictest 
antisepsis. 

Catheterization  which  is  usually  done  by  a  nurse  demands  as 
many  and  as  important  precautions  as  a  big  operation  if  we 
wish  to  avoid  formation  of  a  cystitis.  This  may  even  develop 
in  the  absence  of  catheterization  after  the  extensive  operations 
for  cancer  as  example.  In  these  cases,  as  in  those  where  one  is 
obliged  to  have  recourse  to  catheterization,  we  should  first  give 
a  little  urotropine. 

Gangrenous  cystitis,  which  has  often  been  studied  during  the 
course  of  retroflexion  of  the  gravid  uterus1  and  after  colpo- 
hysterectomies  for  cancer,  may  be  prevented  by  an  appropriate 
treatment  consisting  of  redressing  the  gravid  uterus  at  the  fourth 
month  and  the  peritonization  of  the  denuded  parts  of  the  bladder 
after  removal  of  the  cancer  (Kronig) . 

For  certain  forms  of  rebellious  cystitis  colpocystostomy,  gener- 
ally done  in  America,  renders  useful  service  by  assuring  the  drain- 
age and  continuous  elevation  of  the  bladder.  The  fistula  ought 
only  be  closed  when  the  bladder  condition  is  cured,  if  the  pus 
has  disappeared  from  the  urine  and  the  pressure  of  the  oval- 
headed  sound  on  the  internal  wall  of  the  bladder  causes  no  pain.2 

1  Pinard  and  Varnier,  Ann.  de  gyn.,  Paris,  1887,  T.  VI,  p.  85. 

2  Hartmann,  Painful  Cystitis  and  its  Treatment.     Th.  de  Paris,  G.  Steinheil,  1887. 


TREATMENT  OF  DISEASES  OF  THE   BLADDER  497 

Prolapse  of  the  Vesical  Mucous  Membrane. — This  condition 
has  already  been  observed  to  occur  through  the  meatus.1  It  is 
distinguished  from  prolapse  of  the  urethral  mucous  membrane 
by  the  absence  of  an  orifice  in  its  center  and  by  its  complete 
independence  of  the  canal  in  all  its  length.  Treatment  consists 
in  excision  of  the  prolapsed  mass  after  hypogastric  cystotomy  so 
as  to  see  well  what  one  is  removing  and  not  cause  a  lesion  of 
the  urethra. 

1  Vary,  Hernia  of  the  Bladder  Through  the  Urethra.     Th.   de  Bordeaux,  1894-95. 
No.  82.     Villar,  Arch,  provinc.  de  Chir.,  Paris,  1905,  p.  373. 


32 


CHAPTER  IV. 

TREATMENT  OF  URINARY  FISTULAS. 

Summary. — Vesico-vaginal  fistulas. — Prophylactic  treatment. — Spoon 
taneous  cures. — Preparatory  treatment  (cystitis,  strictures  of  the  vagina). — 
Operation. — General  technic. — Simple  denudation. — Treatment  of  fistulas 
situated  opposite  the  cervix  uteri. — Operations  in  several  stages. — Special 
procedures  applicable  to  large  losses  of  tissue. — Utero-vesical  fistulas  (direct 
and  indirect  obliteration). — Utero- vaginal  fistulas  and  destruction  of  the 
urethra. — Fistulas  of  the  urethra  (T.  prophylactic  and  curative,  T.  by  direct 
obliteration,  by  urethral  grafts,  by  nephrectomy). 

1.  Vesico-vaginal  Fistulas. 

Vesico-vaginal  fistulas  are  due  to  various  causes.  They  are 
frequently  observed  after  difficult  labors. 

Following  on  prolonged  compression  of  the  fetal  head,  the 
tissues  become  gangrenous,  and  as  a  result  there  is  often  con- 
siderable loss  of  substance,  complicated  by  the  presence  of 
faulty  cicatrices  and  adhesions  to  the  neighboring  bones  and 
particularly  the  pubic  arch.  From  this  develop  multiple 
lesions  the  cure  of  which  is  sometimes  most  difficult  as  these 
lesions  may  occur  not  only  in  the  vesico- vaginal  septum,  but  also 
in  the  cervix  uteri,  in  other  parts  of  the  vagina  and  in  the  urethra. 
To-day  owing  to  the  improvement  in  obstetrics  the  number  of 
these  fistulas  has  considerably  diminished;  on  the  contrary,  ope- 
rative fistulas  have  increased  in  number.  They  are  met  with 
after  vaginal  hysterectomy,  total  hysterectomy,  and  in  particular 
colpohysterectomy  for  cancer  and  even  after  certain  surgical 
interventions  such  as  symphysiotomy  and  vaginal  Cesarean 
section. 

The  treatment  of  vesico-vaginal  fistulas  is  still  a  question  of 
the  hour.  Numerous  procedures  are  published  every  day  and 
many  of  them  are  re-editions  of  old  methods.  It  is  important  to 
recognize  the  variability  of  the  lesions  we  have  to  deal  with,  thus 
obliging  the  surgeon  to  recognize  divers  procedures  he  has  to 
follow  according  to  circumstances. 

498 


VESICO- VAGINAL  FISTULAS  499 

I.  Prophylactic  Treatment. 

Prophylactic  treatment  consists  in  the  union  of  vesical 
wounds  at  the  time  of  their  production.  A  non-sutured  wound 
may  sometimes  heal  spontaneously  by  simply  leaving  a  catheter 
in,  but  we  must  not  count  on  this  fact,  but  always  try  and  get 
immediate  union  of  the  operative  lesions  of  the  bladder.  To 
obtain  this  union,  we  avoid  the  insertion  of  perforating  sutures 
and  particularly  those  of  a  non-absorbable  character  like  silk. 
Under  such  circumstances  we  are  exposed  to  the  migration  of  the 
suture  into  the  bladder  and  the  formation  around  it  of  a  secondary 
calculus.  Do,  therefore,  a  suture  in  layers  and  afterward  leave 
in  a  catheter  whenever  possible  and  particularly  after  vesical 
lesions  following  on  colpohysterectomy,  instead  of  leaving  the 
line  of  union  in  contact  with  the  vaginal  wound  and  of  inserting 
a  drain  or  tampon,  try  and  cover  over  the  line  of  suture  with 
the  drawn  down  vesico-uterine  peritoneum,  which  is  the  best 
means  of  obtaining  healing  by  first  intention. 

This  prophylactic  treatment  is  evidently  not  applicable  to 
fistulas  following  on  labor,  which  result  from  the  separation  of 
gangrenous  tissue  and  cannot  consequently  be  immediately 
sutured.  It  has  been  advocated  by  some  to  obtain  a  covering 
by  cauterization  and  in  particular  by  touching  up  with  nitrate 
of  silver  or  the  thermocautery.  The  efficaciousness  of  this 
method  has  not  been  established.  Perhaps,  if  it  is  crowned  with 
success,  it  may  be  merely  a  question  of  one  of  those  spontaneous 
cures  seen  in  a  certain  number  of  cases.  It  is  the  opinion  of  some 
gynecologists  that  these  cauterizations  are  injurious,  because,  if 
a  cure  is  not  obtained,  they  only  lead  to  the  formation  of  cicatri- 
cial  tissue,  the  presence  of  which  renders  later  intervention  more 
doubtful  and  difficult  (Stoeckel). 

It  has  been  advocated  by  others  that  to  favor  the  spontaneous 
cure  of  vesico-vaginal  fistulas  we  should  put  the  patient  in  certain 
positions,  in  ventral  decubitus  to  unilateral  decubitus  on  the 
opposite  side  from  the  fistula.  All  these  methods  have  been 
abandoned  now-a-days. 

We  confine  ourselves  to  the  removal  of  foreign  bodies  if  there 
are  any,  to  vaginal  irrigations  and  to  pelvic  baths  and  to  leaving 
the  catheter  in. 


500  TREATMENT   OF   URINARY  FISTULAS 

As  these  spontaneous  cures  take  a  certain  time  to  come  about 
we  do  not  immediately  operate  on  vesico-vaginal  fistulas,  inas- 
much that  after  labor  the  tissues  are  more  friable  and  more 
vascular,  that  in  the  fistulas  which  supervene  on  a  surgical  inter- 
vention there  often  exists  a  neighboring  suppuration,  which  may 
prevent  the  insertion  of  the  suture.  We  must  wait  until  the 
fistula  ceases  to  diminish  spontaneously  and  the  tissues  have 
taken  on  their  normal  appearance  and  there  are  no  pathological 
secretions  in  the  neighborhood. 

We  will  not  be  able  to  operate  before  the  sixth  or  tenth  week; 
in  general,  the  patients  themselves  decide  tardily  for  an  operation. 

If  an  operation  has  failed  wait  two  or  three  months  before 
deciding  to  do  a  second  operation. 

II.  Pre -operative  Treatment. 

The  first  point  is  to  treat  the  vagina  and  the  bladder.  If  we 
have  incrustations  of  lime,  ulcerated  or  granulated  surfaces,  we 
must  cure  these,  and  modify  the  alkalinity  of  the  urine  by  repeated 
injected  hot  boric  acid,  and  afterward  drying  the  vagina  and 
vulva  with  tampons  of  cotton  wool  held  in  forceps  and  then 
applying  nitrate  of  silver  to  the  ulcerated  surfaces.  If  at  the 
same  time  as  the  communication  with  the  bladder  there  exists 
a  recto-vaginal  fistula  do  away  with  the  latter,  so  as  to  avoid 
infection  from  the  intestine. 

When  the  vagina  is  constricted  by  cicatrices,  commence  gradu- 
ally to  dilate,  doing  repeated  tamponing  with  antiseptic  gauze 
or  by  introducing  a  series  of  gradually  increasing  aluminium 
balls.  Continue  the  dilatation  until  we  no  longer  find  any 
cicatricial  band  projecting  into  the  vagina.  The  resistant  bands 
should  be  severed  under  visual  control  and  with  great  prudence, 
particularly  those  which  border  on  the  rectum  or  posterior  fornix. 

This  preliminary  dilatation  which  the  American  surgeons, 
Sims  and  Bozeman,  have  so  well  studied  is  still  practised,  but 
rejected  by  the  majority.  It  is  quite  certain  that  it  gives  a  good 
dilatation  and  that  it  leads  to  a  relaxation  of  and  at  the  same 
time  a  freeing  of  the  edges  of  the  fistula  in  that  we  do  away  with 
the  retraction  of  the  cicatricial  adhesions  which  draw  in  opposite 
directions,  but  is  difficult  and  painful,  requires  some  weeks  time 


VESICO- VAGINAL  FISTULAS  501 

and  leads  to  an  injurious  maceration  of  the  vagina.  It  does  not 
give  any  better  results.  Personally  we  have  never  had  recourse 
to  it. 

On  the  contrary,  there  is  no  discussion  on  the  necessity  of 
treating  the  lesions  which  may  exist  in  the  urinary  system,  and 
treat  the  pus  in  the  urine  which  is  a  cause  of  non-union  and  of 
dilating  the  possible  strictures  of  the  urethra. 

The  preparations  of  the  operation  are  not  special;  give  a  bath, 
purge  and  shave  the  vulva  the  day  before  and  once  the  patient 
is  anesthetized  do  a  final  cleaning  up  of  the  vagina. 

III.  Operation. 

General  Technic. — The  position  for  operation  is  a  matter  of 
much  discussion.  American  surgeons  have  recourse  to  the  lateral 
or  genu-pectoral  position.  We  prefer  the  dorso-sacral  one.  The 
important  point  is  expose  the  fistula  well.  We  do  this  with 


FIG.  388. — Vaginal  speculum. 

various  retractors  and  drawr  down  the  cervix  when  possible  to 
the  vulva  and  in  stretching  the  walls  of  the  vagina  around  the 
fistula  with  Museux's  forceps  (Fig.  389). 

If  the  fistula  is  inaccessible  because  of  the  cicatricial  bands 
we  should  not  hesitate  to  incise  them,  doing,  if  necessary,  a 
splitting  of  the  vulva  or  even  the  para  vaginal  incision  practised 
by  Schuchardt.1 

1  Michaux  advises  in  cases  of  fistulas  situated  high  up  to  do  an  ischip-rectal  incision 
parallel  to  and  a  good  finger's  breadth  from  the  internatal  cleft.  This  incision  com- 
mences behind  at  the  level  of  the  anus  and  is  directed  forward  for  a  length  of  about  10 
cm.  (3J  inches)  just  to  the  point  where  the  ischio-pubic  arch  and  the  labia  majora 
meet.  Separate  the  ischio-rectal  fat  with  the  fingers  and  press  it  back  toward  the 
tuberosity  of  the  ischium.  The  vagina,  pressed  back  with  the  finger,  is  punctured  3  or 
4  cm.  (1}  inches)  from  the  cervix  and  the  incision  is  made  greater  with  the  scissors. 
(Michaux,  Congres  fran$ais  de  chirurgie,  1892,  p.  717. 


502 


TREATMENT   OF   URINARY   FISTULAS 


Before  tracing  the  surface  of  denudation,  it  is  well  for  the 
last  time  to  determine  in  which  way  the  approximation  of  the 
parts  with  the  greatest  ease  and  without  tension  is  brought 
about.  Having  done  this,  without  hurry  and  without  tearing 
the  parts  by  drawing  on  them  too  violently,  commence  the 
denudation.  We  must  stretch  the  parts  about  to  be  cut  and 
use  a  very  sharp  knife.  Special-curved  probe-pointed  bistouries, 
which  are  often  used,  are  useless  and  of  little  value;  a  scalpel 
with  a  long  handle  is  sufficient.  The  venous  hemorrhage 


FIG.  389. — Vesico-vaginal  fistula  is  well  exposed  by  drawing  down  the  cervix  and  by 

traction  on  the  vaginal  walls. 

which  occurs  is  of  no  importance  and  the  insertion  of  sutures 
suffices  to  stop  it;  on  the  contrary,  if  there  is  an  arterial  spurt 
put  a  fine  catgut  about  the  vessel ;  serious  hemorrhages  may  come 
on  as  a  result  of  the  neglect  of  this  precaution. 

In  union  we  use  sutures  taking  up  the  various  planes,  catgut 
for  the  deepest  and  silkworm-gut  or  silver  wire  for  the  sutures  that 
project  into  the  vagina.  For  suturing  in  one  plane  we  use  only 
non-absorbable  sutures. 

This  small  consideration  of  general  technic  in  the  operations 
on  fistulas  shows  us  that  recent  progress  denotes  a  return  to 
simplicity;  the  complicated  instruments  still  to  be  found  at  the 


VESICO- VAGINAL  FISTULAS 


503 


makers'  are  useless  and  the  usual  instruments  are  sufficient  with- 
out having  recourse  to  special  ones. 

Simple  Denudation. — Simple  denudation  is  the  most  com- 
monly employed  procedure.  It  should  be  extensive,  more  than 
1  cm.  (1-/2  inch)  and  should  comprise  the  vaginal  mucous 
membrane  and  all  the  thickness  of  the  septum  with  the  exception 
of  the  vesical  mucous  membrane. 


FIG.  391. — Probable  failure  owing 
to  the  smallness  of  the  surface  of  denu- 
dation; possible  incrustations  on  the 
intra- vesical  portion  of  the  sutures. 


FIG.  390.- — Too  small  a  denudation,  car- 
ried out  on  the  vesical  mucous  membrane, 
and  perforating  sutures.  (Three  faults.) 


With  the  scalpel  incise  the  vagina  superficially  around  the 
fistula.  Having  done  this  seize  the  flap  to  be  removed  with  a 
pair  of  toothed  forceps  and  excise  with  the  scalpel,  taking  care 


FIG.  392. — Extensive  vaginal  denudation 
with  the  sutures  approximating  a  large  extent 
of  tissue  and  passing  below  the  vesical  mucous 
membrane. 


FIG.  393. — The  parts  are  well  and 
freely  approximated;  the  sutures  do 
not  perforate  the  bladder. 


to  cut  the  tissues  decisively  and  obliquely  right  to  the  end  of  the 
fistula.  This  denudation  should  be  complete.  If  there  are  any 
non-denuded  portions,  draw  upon  them  and  excise  them  after- 
ward with  fine  curved  scissors. 


FIG.  394. — Denudation  in  stair  formation  (bad). 


FIG.  395. — After  the  denudation 
the  parts  approximate  badly. 


The  denudation  should  be  done  obliquely  from  the  vagina  to 
the  bladder.  A  stair-like  denudation  does  not  tend  to  a  complete 
approximation  of  the  surfaces  (Figs.  394  and  395).  During  the 
whole  stage  of  the  denudation,  an  assistant  with  a  stream  of 


504 


TREATMENT    OF   URINARY   FISTULAS 


saline  washes  away  the  blood  from  the  field.  The  denudation 
having  been  finished  a  temporary  compression  with  a  sterilized 
gauze  tampon  suffices  to  stop  the  hemorrhagic  oozing. 

All  that  now  remains  is  to  unite  the  denuded  parts.  The 
sutures  should  pass  under  the  denuded  surface,  and  take  up 
extensive  and  symmetrical  surface,  and  should  not  be  too 
numerous,  having  an  interval  of  1/2  to  1  cm.  as  a  rule  between 
them. 

We  must  tie  them  sufficiently  to  bring  the  parts  \vell  into 
contact,  but  avoid  the  constriction  of  the  tissues  so  as  not  to 
cause  them  to  become  gangrenous. 


FIG.  396. — Suture  after  denudation. 

We  use  sharply  curved  needles,  held  in  a  needle  holder,  to 
insert  them  and  using  a  tenaculum  sometimes  to  fix  the  tissues 
while  we  pass  the  needle.  Commence  by  passing  a  medium 
suture,  which  enters  the  vaginal  mucous  membrane  about  3  mm. 
from  the  edge  of  the  denudation  and  appears  just  below  the  vesical 
mucous  membrane  and  then  takes  up  the  lip  on  the  other  side. 

The  two  ends  of  the  suture  are  seized  with  pressure  forceps ; 
insert  other  sutures  afterward  and  only  commence  to  tie  them 
when  they  are  all  in  position.  The  union  of  the  denuded  surface 


VESICO- VAGINAL  FISTULAS  505 

is  done  in  the  most  favorable  sense  as  regards  the  approximation 
of  the  parts,  by  following  an  oblique  curved  line  shaped  like  a  U; 
the  only  point  of  importance  is  to  avoid  lines  of  sutures  that 
cross  like  an  H  or  Y,  etc. ;  the  point  of  intersection  of  two  lines  of 
sutures  always  constitutes  a  weak  point. 

If  the  fistula  is  situated  near  the  neck  of  the  bladder,  we  must 
think  of  the  ureters  and  make  certain  before  commencing  the 
operation  that  they  do  not  open  on  its  borders.  In  such  a  case 
we  must  dissect  them  a  little  in  order  to  return  them  toward  the 
bladder  and  be  careful  when  passing  the  sutures  at  their  level 
not  to  take  up  too  much  tissue  in  order  to  be  sure  of  obliterat- 
ing them. 

When  the  denuded  surfaces  cannot  be  approximated,  we 
should  mobilize  the  fixed  parts.  In  a  case  where  the  fistula 
adheres  by  one  of  its  extremities  to  the  pubis,  Kelly  merely  intro- 
duces a  tenotome  through  the  vulva  about  3  cm.  (1  1/4  inches) 
from  the  fixed  point  and  by  the  subcutaneous  route  frees  the 
bony  adhesion. 

Generally  we  confine  ourselves  to  continuing  the  denudation 
by  a  more  or  less  lengthy  incision  and  its  edges  are  separated ;  at 
other  times  on  a  line  with  the  cicatrix  we  split  laterally  or  else 
we  combine  these  two  procedures,  i.e.,  WTC  separate  up  a  flap  and 
then  parallel  to  it  make  an  incision  so  as  to  render  the  tissues 
mobile.  Finally,  when  the  surface  of  denudation  has  been  modi- 
fied afterward  by  adding  two  secondary  denudations  to  the  ex- 
tremities of  the  primary  denudation  suture  these  latter  so  as  to 
approximate  the  parts  at  their  level  and  to  have  in  the  center,  at 
the  fistula,  the  tissues  approximated  without  tension. 


FIG.  397. — de  Pezzer's  catheter. 

When  the  operation  is  finished,  we  tampon  the  vagina  lightly 
with  iodoform  gauze  and  leave  in  a  catheter.  The  best  thing  to 
do  is  to  use  a  de  Pezzer's  catheter,  which  is  easily  introduced  into 
the  female  urethra  and  which  remains  in  good  position  without 
any  need  of  being  fixed  in.  If  one  does  not  possess  this  catheter, 
use  a  simple  rubber  tube,  which  is  introduced  after  an  injection 


506  TREATMENT   OF   URINARY  FISTULAS 

of  boracic  acid  into  the  bladder,  until  the  fluid  flows  out  of  the  tube ; 
the  tube  at  this  moment  projects  just  beyond  the  sphincter;  fix  it 
to  the  meatus  by  a  suture  to  hold  it  in  good  position.  Leave  the 
catheter  in  for  about  a  week  and  give  the  patient  about  20 
grains  of  urotropine  daily;  wash  out  the  bladder  daily  with  a 
feeble  solution  of  silver  nitrate  (1  to  1000)  if  there  is  pus  in  the 
urine. 

The  sutures  are  taken  out  progressively  from  the  tenth  to  the 
fourteenth  day  under  visual  control;  always  press  the  fourchette 
down  with  a  Sims'  speculum.  If  one  does  not  see  them  clearly, 
feel  them  gently  with  the  finger,  so  as  to  determine  their  situation 
at  once. 

Splitting. — Denudation  by  splitting  of  tissues  may  be  done  in 
two  different  ways,  either  proceeding  from  the  fistulous  orifice  or 
in  proceeding  from  an  incision  encircling  the  fistula  and  passing 
about  1  1/2  cm.  outside  the  incision. 

1.  Denudation  by  Splitting  Outward  from  the  Fistula. — De- 


FIG.  398. — Denudation  by  splitting  outward  FIG.  399. — Suture  after  splitting, 

from  the  fistula. 

scribed  by  Gerdy  in  1841,  and  then  abandoned  in  favor  of  denuda- 
tion, this  procedure  was  taken  up  again  in  1864  by  Duboue  and 
then  in  1896  by  Phenomenon7,  Ricard1  and  others.  Around  the 
entire  circumference  of  the  fistulous  orifice  at  the  union  of  the  va- 
ginal and  vesical  mucous  membrane  and  in  the  cicatricial  tissue  is 
made  an  incision  which  is  prolonged  on  each  side  into  the  vaginal 
mucous  membrane.  It  is  then  easy  to  split  each  of  the  lips,  in 
cleaving  its  vesical  and  vaginal  walls  over  a  variable  extent  of 
1  to  3  cm.  (Figs.  398  and  399). 

Having  done  this  splitting  at  the  base  of  the  wound  we  see 
the  freed  bladder,  limp  and  floating  around  the  fistulous  orifice. 
Close  it  with  a  fine  non-perforating,  purse-string  or  continuous 

1  Ricard,  Congresfran  de  chir.,  Paris,  1896,  p.  927. 


VESICO-VAGINAL  FISTULAS 


507 


catgut  and  then  suture  the  vaginal  flaps  above,  being  careful  to 
pass  the  sutures  through  their  base  on  a  level  with  the  dehedral 
angle  resulting  from  the  splitting  (Fig.  400). 


FIG.  400. — Suture  after  splitting  outward  from  the  fistula;  the  vesical  mucous  mem- 
brane is  united;  the  vaginal  sutures  are  inserted,  but  not  tied. 

2.  Splitting  Outward  from  an  Incision  at  a  Distance  from  the 
Fistula. — Braquehaye1  makes  an  incision  at  a  little  distance  from 
the  fistula.  The  incision  encircles  it  and  then  splits  the  vesico- 
vaginal  septum  in  being  directed  from  the  incision  to  the  fistulous 
orifice  (Fig.  401). 


FIG.  401. — Splitting  by  an  incision  made 
at  a  distance. 


FIG.  402. — Suture  of  the  under  cut 
vesical  mucous  membrane.  Insertion  of 
vaginal  sutures. 


We  must  make  a  circular  incision  7  mm.  above  and  12  below 
the  fistula  and  then  dissect  up  the  islet  of  mucous  membrane  of  the 
vagina,  thus  circumscribed  to  within  2  or  3  cm.  of  the  edge  of  the 

1  Braquehaye,  Cong,  franfais  de  Chir.,  Paris,  1899,  p.  659,  et  Bull,  et  Mem.  de  la 
Soc.  de  chir.,  Paris,  1900,  p.  988. 


508 


TREATMENT   OF   URINARY   FISTULAS 


fistula.  We  have  thus  a  collarette  of  mucous  membrane  adherent 
to  the  fistula  itself  by  a  circular  pedicle.  This  collarette  is  turned 
back  into  the  fistulous  orifice  in  such  a  manner  that  its  mucous 
membrane  surface  faces  the  cavity  of  the  bladder  and  its  raw 
surface  the  vagina.  Suture  it  together  with  fine  catgut.  Then 
insert  the  vaginal  sutures,  burying  the  collarette  that  was  primarily 
sutured  (Figs.  402 -and  403). 


FIG.  403. — Suture  after  splitting  by  an  incision  at  a  distance ;  the  collarette  of  mucous 
membrane  is  pushed  back  toward  the  bladder  by  a  catgut  purse-string  suture ;  the  vaginal 
sutures  are  inserted,  but  not  tied.  If  they  are  tied  the  line  of  the  vaginal  union  will  be 
posteriorly  situated  to  the  bladder  suture  because  of  the  asymmetry  of  the  primary 
incision. 

The  closing  is  so  much  the  more  certain  if  the  original 
circular  incision  does  not  pass  at  equal  distance  from  the  borders 
of  the  fistula  and  thus  in  consequence  the  two  lines  of  suture  do 
not  correspond. 

We  have  found  this  procedure  very  practical  for  closing 
fistulas  situated  at  the  far  end  of  an  inf undibulum ;  we  have 
thus  cured  fistulas  with  the  greatest  facility  which  had  followed 
on  vaginal  hysterectomies,  our  colleagues  having  vainly  attempted 
to  close  them  by  other  means.  The  incision  is  made  anteriorly 
to  the  fistula,  which  lies  at  the  far  end  of  the  cicatricial  tunnel 
and  which  corresponds  to  the  vaginal  fornix.  The  operation  is 
simply  carried  out  afterward. 


VESICO-VAGINAL  FISTULAS 


509 


Treatment  of  Fistulas  Situated  in  the  Neighborhood  of  the 
Cervix  Uteri. — When  working  near  a  rigid  cervix  whose  tissues 
cannot  be  placed  in  opposition  like  those  of  the  vagina  and  when 
confroted  with  a  fairly  long  fistulous  track,  we  must  deal  with 
it  in  a  special  manner  other  than  simple  denudation  of  the  vagina. 
From  an  oval  incision  encircling  the  fistula,  branch  off  at  the  level 
of  the  junction  of  the  vagina  and  cervix  with  a  transverse  incision 
and  then  split  the  vesico-uterine  septum  until  the  upper  limits 


FIG.  404. — Denundation  of  a  fistula  against  the  cervix  uteri. 

of  the  fistula  have  been  passed.  Then  completely  excise  the  tract 
of  the  fistula,  suture  the  vesical  and  the  uterine  gaps  separately 
and  terminate  by  closing  the  vagina  (Figs.  404  and  405). 

Operations  in  Several  Stages. — Sometimes  one  fails  in  the 
treatment  of  a  vesico-vaginal  fistula.  Fritsch  advises  then  to 
make  the  line  of  denudation  of  the  second  operation  perpendicular 
to  that  of  the  former  operation,  and  to  tie  the  sutures  so  that 
the  twro  sides  of  the  old  cicatrix  do  not  correspond  to  each  other 
(Fig.  406) .  The  operation  in  several  stages  may  be  done  deliber- 


510 


TREATMENT   OF    URINARY   FISTULAS 


ately.  It  is  that  in  presence  of  very  irregular  fistulas  there  is 
often  an  advantage  in  not  trying  to  obtain  at  first  a  closure  of 
all  the  fistula,  but  to  confine  oneself,  as  Fritsch  does,  to  suturing 


FIG.  405. — Suture  after  excision  of  a  fistulous  tract. 


FIG.  406. — Denudation  and  suture  of  a  fistula  in  a  cicatrix  of  a  former  operation. 

• 

one  of  its  prolongations,  and  only  to  close  the  remainder  a  month 
afterward,  taking  care  that  the  second  suture  is  in  a  sense  per- 
pendicular to  the  direction  of  the  parts  already  united  (Figs.  406 
and  407). 


VESICO- VAGINAL  FISTULAS 


511 


jTSpecial  Procedures  Applicable  to  Large  Losses  of  Substance.— 
If  the  fistula  is  very  wide  and  there  are  at  the  same  time  extensive  cicatrices 
of  the  vaginal  wall,  the  procedures  we  have  just  described  are  insufficient. 
It  is  impossible  to  approximate  the  edges  of  such  an  extensive  area,  where 
generally  the  sutures  cut  through  and  the  wound  reopens. 

Flaps. — In  the  case  of  a  broad  fistula  occupying  almost  the  whole  extent 
of  the  vesico-vaginal  septum,  A.  Martin1  makes  a  few  incisions  in  the 
vaginal  mucous  membrane  at  a  certain  distance  from  the  fistula  and  parallel 
to  it,  which  enable  him  to  free  the  vagina  while  working  toward  the  fistula; 


FIG.  407. — Partial  obliteration  of  a  pro 
longation  of  the  fistula. 


FIG.  408. — The  prolongation  is  closed. 
Denudation  and  suture  of  what  remains  of 
the  fistula. 


the  two  flaps  thus  incised  are  directed  toward  the  bladder  and  then  sutured, 
while  the  vaginal  wounds  are  united  afterward  in  a  colporraphy. 

Trendelenburg2  sutures  a  horse-shoe  shaped  flap  to  the  lateral  and  inte- 
rior edges  of  the  fistula.  This  flap  is  detached  by  three  of  its  sides  from  the 
posterior  wall  of  the  vagina.  He  does  a  second  stage,  four  weeks  later,  and 
cuts  the  pedicle  of  the  flap  and  fixes  it  to  the  posterior  part  of  the  denuded 
fistula. 

Odenthal3  cuts  two  lateral  flaps  having  their  pedicle  at  the  level  of  the 
fistula;  he  directs  them  toward  the  bladder  and  then  sutures  them. 

Fritsch  advises  the  operation  to  be  done  in  the  following  manner:  he 
freshens  the  fixed  edge  of  the  fistula  and  then  files  the  mobile  edge  by 

1  A.  Martin,  Zeitsch.  f.  Geb.  und  Gyn.,  1891 ,  No.  19,  p.  394.     Rydygier  avait  d6ja 
eu  recours  &  la  taille  de  lambeaux  vaginaux  au   voisinaee   de   la  fistule    (Rvdvgier, 
Berl.  klin.  Woch.,  1887,  No.  31). 

2  Trendelenburg,  Samml.  klin.  Woch.,  1890,  No.  355. 

3  Odenthal,  Centr.-Bl.f.  Gyn.,  Aug.  17,  1901,  p.  945. 


512 


TREATMENT   OF   URINARY  FISTULAS 


cutting  a  flap  much  larger  than  would  be  required  to  fill  the  orifice  and  as 
thick  as  possible.  This  flap  is  drawn  over  the  surface  to  be  covered. 
It  is  fixed  by  a  primary  row  of  fine  catguts  uniting  its  deep  surface;  the 
superficial  sutures  should  exercise  no  traction  and  are  only  inserted  if  the 
flap  has  a  tendency  to  be  displaced. 

Liberation  of  the  Bladder. — Described  and  carried  out  by  Jobert  under 
the  name  of  vesical  autoplasty  by  "glissement  ou  locomotion,"  the  rendering 
mobile  of  the  bladder  has  latterly  been  utilized  by  a  certain  number  of 
surgeons.  E.  C.  Dudley  in  one  case  mobilized  the  vesical  mucous  membrane 
behind  the  fistula,  and  then  sutured  it  to  the  anterior  part  already  denuded 
on  its  vaginal  surface. 


FIG.  409. — Freeing  of  the  bladder.  By  an 
incision  we  split  the  vesico-uterine  septum 
along  the  whole  length  of  of. 


FIG.  410. — The  bladder  having 
been  freed  the  loss  of  substance  is 
done  away  with  by  the  edges  being 
sutured ;  /  is  now  in  contact  with  /'. 


Mackenrodt 1  makes  a  long  median  incision  in  the  vaginal  wall,  extending 
in  front  of  and  behind  the  fistula,  and  then  he  splits  the  vesico-vaginal  septum 
laterally  and  antero-posteriorly.  He  carries  out  this  separation  of  the 
bladder,  if  necessary,  as  far  as  the  vesico-uterine  fold.  Having  thus  freed 
the  entire  base  of  the  bladder,  he  is  in  apposition  to  suture  it  as  in  the  diagram, 
by  uniting  the  edges  of  the  loss  of  substance.  The  vaginal  wound  is  after- 
ward closed  and  the  uterus  drawn  down  and  if  necessary  it  is  used  to  close 
the  perforation. 

1  Mackenrodt,  Centr.-Bl.  f.  Gyn.,  Leipzig,  1894,  No.  8,  p.  180. 


VESICO-VAGINAL  FISTULAS  513 

Kelly 1  has  recourse  to  mobilization  of  the  bladder.  He  makes  a  crescent- 
shaped  incision  behind  the  fistula  and  separates  the  part  in  front  of  the  vagina 
and  cervix  uteri. 

The  danger  of  these  procedures  of  vesical  mobilization  is  the  possibility 
of  injuring  the  uterus,  which  is  sometimes  displaced  by  cicatricial  retrac- 
tions. 

Utilizing    the    Uterus. — Freund2  has  used  the  body  of  the  uterus,  in 

order  to  close  large  fistulas,  the  body  of  the  uterus  attached  in  the  vagina 

after    posterior  colpotomy.     The  uterus  is  fixed  as  in  the  operation  for 

"Bascule"  of  the  uterus  where   it   is   drawn    down  into  the  vagina  and 

fixed  with  the  fundus  below. 

Occlusion  with  the  Anterior  Lip  of  the  Cervix. — Wolkowitsch  and  Kiistner 
detached  the  cervix  and  drew  down  the  uterus  and  then  after  excision  of  the 
cicatricial  ring  encircling  the  fistula,  stopped  it  up  by  uniting  it  with  the 
denuded  cervix. 

Occlusion  with  the  Posterior  Lip  of  the  Cervix. — In  certain  fistulas  invading 
the  cervix,  its  anterior  lip  may  be  wanting  completely  and  in  such  a  case  we 
suture  the  posterior  lip  of  the  cervix  to  the  edges  of  the  fistulous  orifice. 
Menstruation  occurs  by  the  bladder  and  results  in  no  inconvenience. 

Occlusion  with  the  Vesico-uterine  Peritoneum. — Bumm  and  Doderlein  do  a 
hysterectomy,  and  then  use  the  vesico-uterine  peritoneum  in  order  to  close 
the  fistula.  Bardescu  draws  down  the  vesico-uterine  peritoneum,  but 
without  doing  a  preliminary  hysterectomy  and  confine  themselves  to  doing 
an  anterior  colpotomy. 

Autocystoplasty  and  Colpocystoplasty. — Profiting  by  the  fact  that  mucous 
membrane  of  the  antero-superior  wall  of  the  bladder  often  causes  a  hernia 
into  the  vagina  through  the  fistula,  Witzel3  simply  denudes  the  hernial  pro- 
trusion of  vesical  mucous  membrane  and  sutures  it  to  the  lips  of  the  denuded 
fistula.  This  operation  had  the  inconvenience  of  definitely  preserving  an 
abnormal  condition,  i.e.,  the  prolapse  through  fistula  and  of  partitioning 
the  bladder  and  of  leading  to  injuries  of  the  ureter.  Witzel  abandoned  it 
for  an  operation  which  is  almost  the  opposite.  By  a  suprapubic  incision 
he  seizes  the  posterior  wall  of  the  vagina  through  the  fistula  and  draws  it  into 
the  bladder,  denudes  its  surface  and  fixes  it  to  the  freshened  edges  of  the 
fistula.  At  a  second  stage  and  after  perfect  cicatrization,  he  separates  the 
part  of  the  vagina  fixed  in  the  bladder  from  the  vaginal  canal,  which  is  then 
reconstituted  by  suture. 

Suprapubic  Incision. — Trendelenburg4  places  the  patient  in  the  position 

1  Howard  A.  Kelly,  Johns  Hopkins  Bulletin,  Baltimore,  Feb.,  1896. 

2  Freund,  W.  A.,  Samml.  klin.  Wortr.,  1895,  No.  118. 

3  Witzel,  Ann.  de  Gyn.,  Paris,  1901,  T.  I,  p.  285. 

4  Trendelenburg,  Ueber    Blasenscheidenfisteloperationen  und  iiber  Beckenhochlage- 
rung  bei  Operationen  in  der  Bauchhohle.     Samml.  klin.  Wortr.,  Leipzig,  1890,  No.  355. 

33 


514  TREATMENT   OF   URINARY  FISTULAS 

associated  with  his  name  and/then  does  a  transverse  suprapubic  incision  and 
by  this  proceeding  he  freshens  the  fistula  and  then  sutures  it  with  sutures 
having  a  needle  threaded  to  each  end  so  that  the  two  extremities  may  ap- 
pear in  the  vagina  and  are  tied  in  that  canal. 

Colpoclesis. — After  simple  colpoclesis  or  occlusion  of  the  vagina,1  he 
brings  about  a  stagnation  of  urine  in  the  vaginal  f  ornix  which  has  now  become 
a  diverticulum  of  the  bladder.  This  leads  to  the  formation  of  phosphatic 
calculi  whose  dimensions  may  become  very  considerable. 

The  pains  lead  to  a  destruction  of  the  septum  formed  and  things  are 
restored  to  their  former  state.  However,  better  technic  in  the  treatment  of 
vesico-vaginal  fistulas  has  caused  us  to  abandon  this  method  of  treatment. 

There  are,  however,  cases  where  the  ureter  has  been  destroyed  at  the  same 
time  as  the  vesico-vaginal  septum  and  where  the  attempts  at  its  restoration 
are  constantly  followed  by  failure.  Fritsch  advises  a  combination  of  a  recto- 
vaginal  fistula  with  a  colpoclesis. 

The  important  point  is  that  there  should  not  be  any  stagnation  of  urine  in 
the  vagina.  To  avoid  it,  make  the  recto- vaginal  fistula  as  low  as  possible,  im- 
mediately above  the  sphincter,  and  incise  the  parts  transversely,  which  results 
in  the  production  of  a  fold  of  rectal  mucous  membrane  serving  as  a  valve. 
Then  excise  from  the  vagina  a  ring  of  mucous  membrane,  and  close  it  by  a 
sagittal  suture.  Diminish  as  much  as  possible  the  capacity  of  the  vagina, 
and  denude  in  an  oblique  direction,  so  that  it  terminates  exactly  at  the 
recto-vaginal  fistula,  and  no  cul-de-sac  lies  above  it. 

Che'nieux2  combines,  in  certain  urethro-vesico-vaginal  fistulas  an  epis- 
rorraphy  with  a  hypogastric  meatus. 

2.  Vesico -uterine  Fistulas. 

Vesico-uterine  fistulas  have  been  treated  either  by  direct  or 
indirect  obliteration. 

Direct  Obliteration. — By  a  transverse  incision  is  brought 
about  the  separation  of  the  cervix  uteri  and  the  bladder.  The 
separation  is  continued  for  a  very  considerable  distance  round 
the  fistulous  opening.  The  edges  of  the  bladder  portion  of  this 
are  then  freshened  and  sutured. 

The  uterine  portion  of  the  fistulous  passage  is  excised  and 
sutured.  This  done,  the  cervix  is  fixed  anew  to  the  vault  of  the 
vagina.3 

Dittel,  then  Forgue,  have  had  recourse  to  the  transperitoneal 

1  A.  le  Double,  Du  Kleisis  genital  et  principalement  de  1'occlusion  vaginale  et  vulvaire 
dans  les  fistules  uro-genitales.     Th.  de  Paris,  1876. 

2  Chenieux,  Rev.  de  gyn.  et  Chir.  Abd.,  Paris,  1906,  p.  21. 

3  Herff,  Zeitsch.f.  Geb.  u.  Gyn.,  Stuttgart,  1891,  T.  XXII,  p.  1. 


VESICO-UTERINE  FISTULAS  515 

route.1  After  an  incision  of  the  utero-vesical  pouch,  encroach- 
ing on  the  anterior  surface  of  the  broad  ligaments,  the  bladder 
is  carefully  separated  from  the  cervix  till  the  fistula  is  reached, 
which  is  then  slit  across,  and  any  fibrous  masses  present  are 
excised ;  then  the  edges  of  the  fistula  are  freshened.  The  fistulous 
openings  on  the  vesical  and  uterine  sides  are  successively  sutured ; 
then  the  utero-vesical  peritoneum  is  replaced. 

Indirect  Obliteration.— Indirect  obliteration  is  very  simply 
obtained  by  denuding  and  then  suturing  the  lips  of  the  cervix 
(hysterocleisis) .  Menstruation  then  occurs  through  the  bladder. 

3.  Utero- vaginal  Fistulas  with  Destruction  of  the  Urethra. 

The  treatment  for  small  fistulas  is  the  same  as  that  of  running 
vesico-vaginal  fistulas;  but  when  there  is  almost  complete  destruc- 
tion of  the  urethral  canal,  an  autoplastic  operation  must  be 
resorted  to,2  cutting  flaps  at  the  expense  of  the  vagina  and  vulva. 
In  some  cases  it  has  been  possible  to  use  flaps  from  a  persistent 
part  of  the  utero-vaginal  septum. 

We  cannot  describe  all  the  various  methods  of  procedure  here 
they  are  so  numerous. 

Fritsch  makes  an  incision  on  each  side  of  the  urethral  gutter, 
separates  the  urethra  from  the  vagina,  folds  it  in  on  itself,  and 
then  covers  it  with  the  separated  vaginal  wall. 

Pean  cut  two  vulvo- vaginal  flaps  and  folding  them  over  toward 
the  middle  line  suturing  one  to  the  other,  thus  reconstructing  a 
urethral  canal ;  he  then  marked  out  a  flap  on  each  side  sufficiently 
large  to  cover  over  the  bleeding  surface  left  by  the  last  flaps,  at 
the  same  time  replacing  the  loss  of  substance  their  removal  had 
caused.  For  this  purpose  he  dissected  freely  from  within  out- 
ward the  integuments  of  the  vagina  and  vulva,  till  it  wras  possible 
to  bring  the  inner  borders  of  the  flaps  in  contact  by  sliding  them 
up,  and  then  he  sutured  them  together.  Thanks  to  the  laxity  of 
the  tissues  in  this  region,  this  second  part  was  easily  performed. 
He  sutured  these  two  flaps  a  little  out  of  the  middle  line,  so  that 
there  would  not  be  two  layers  of  suture  lying  together,  one 
superimposed  directly  on  the  other.  The  operation  wras  finished 

1  Forgue,  Revue  de  gynecologic  et  chirurgie  abdominale,  Paris,  1906,  p.  503. 

2  Delbecque,  De  la  restauration  de  1'uretre  chez  la  femme,  Th.  de  Paris,  1892,  No.  263. 
Cottard,  Traitment  opgratoire  de  I'incontinence  d'urine  chez  la  femme.     Th.  de  Paris, 
G.  Steinheil  1906-1907,  No.  63. 


516 


TREATMENT   OF   URINARY   FISTULAS 


FIG.  411. — Incision  for  vulvo-vaginal  flaps. 


FIG.  412. — The  flaps  are  folded  over  to  form  a  canal. 


VESICO-UTERINE  FISTULAS 


517 


by  the  union  of  the  anterior  borders  of  the  flaps  surrounding  the 
new  meatus  (Figs.  411,  412,  413).  Others  have  commenced  by 
forming  a  canal  on  a  level  with  the  vestibule  and  then  have  fixed 
to  the  posterior  border  of  this  new  urethra  a  flap  cut  at  the  expense 
of  the  vesieo-vaginal  septum  and  brought  across. 

Noble  has  ingeniously  modified  this  part  of  the  operation  by 
dissecting  a  broad  strip  of  tissue  on  the  anterior  wall  of  the  vagina, 


FIG.  413. — The  raw  surfaces  are  covered  by  the  sliding  up  of  lateral  flaps. 

having  its  apex  downward  and  its  base  at  the  level  of  the  vesico- 
urethral  opening.  With  a  pair  of  forceps  introduced  through 
the  canal  he  has  made,  he  draws  this  strip  through,  and  fixes  it 
with  fine  silk  to  the  new  meatus  (Fig.  414). 

As  the  leaving  in  of  a  catheter  and  catheterization  are  often  the 
cause  of  nonunion,  Fritsch  advises  bladder  puncture  and  the  fixing 
in  the  perforation  of  a  small  catheter  till  the  flaps  have  united. 

Whatever  method  has  been  employed,  a  complete  continence 
of  urine  can  hardly  be  expected ;  one  can  remedy  this  by  the  use 
of  a  pessary  with  a  suburethral  pad,  which  presses  the  walls  of  the 
new  urethra  together  and  hinders  the  outflow  of  urine. 

In  inoperable  cases,  the  patient  is  condemned  to  the  carriage 


518 


TREATMENT   OF   URINARY  FISTULAS 


of  a  urinal  or  to  a  colpoclesis  with  a  rectal  fistula  or  a  hypogastric 
cystotomy. 


FIG.  414. — Closing  of  the  urethro-vesical  orifice. 


FIG.  415.— Urinal. 

4.  Fistulas  of  the  Ureter. 

Fistulas  of  the  ureter  are  the  result  of  traumatism  either  dur- 
ing labor  or  more  often  now-a-days  during  gynecological  opera- 
tions. 


FISTULAS  OF  THE  URETER  519 

Prophylactic  Treatment. — An  exact  knowledge  of  the  course 
of  the  ureter,  and  the  employment  of  well  arranged  proceedings 
in  an  operation,  so  avoiding  a  lesion  of  the  ureter.  If,  however, 
in  the  course  of  an  operation,  a  lesion  of  this  canal  is  discovered, 
it  must  be  treated  immediately. 

We  refer  to  a  former  work  for  the  study  of  the  various  meth- 
ods of  dealing  with  this  condition.1 

Curative  Treatment.— Fistulas  of  the  ureter  may  heal  up 
spontaneously ;  thus  some  which  are  kept  up  by  the  presence  of  a 
ligature  and  close  up  directly  this  is  removed.  This  cicatrization 
is  only  obtained,  however,  in  cases  where  the  loss  of  substance  is 
restricted  to  one  part  of  the  circumference  of  the  canal.  Speaking 
generally,  a  fistula  which  lasts  for  more  than  six  weeks  gives 
very  little  hope  of  spontaneous  cure.  It  is  then  necessary  to 
have  recourse  to  a  surgical  operation;  beforehand,  all  that  is  to 
be  done  is  to  insure  as  complete  asepsis  as  possible  of  the  region 
of  the  fistulous  opening,  and  to  treat,  if  it  occurs,  the  concomitant 
cystitis,  the  danger  being  above  all  the  pyelonephritis  that  may 
result.  In  the  presence  of  a  fistula  of  the  ureter,  the  surgeon 
possesses  a  series  of  methods  of  treatment  which  may  be  classed 
under  three  heads :  first,  plastic  occlusion ;  second,  ureteral  graft- 
ing; third,  nephrectomy. 

I.  Plastic  Occlusion. 

The  first  attempts  at  plastic  occlusion  were  unsuccessful,  and 
it  was  not  till  the  work  of  Landau  that  healing  of  ureteral  fistulas, 
after  a  simple  plastic  operation  through  the  vagina,  occurred. 

Landau  distinguishes  the  cases  where  the  vesical  end  of  the 
ureter  is  permeable  and  those  in  which  it  is  impermeable. 

If  the  vesical  end  is  permeable  a  catheter  should  be  introduced, 
one  end  going  toward  the  kidney,  the  other  passing  down  through 
the  bladder  and  urethra.  Leaving  the  catheter  in  place,  the  edges 
of  the  uretero-vaginal  opening  are  freshened  and  then  united  by 
several  sutures.  If  the  vesical  end  is  impermeable,  an  incision 
is  made  along  it  till  the  bladder  is  penetrated.  From  each  side 
of  this  incision,  a  certain  quantity  of  vesical  and  vaginal  mucous 

1  Hartmann,  Chirurgie  des  organs  g£nito-urinaires  de  1'homme,  Paris,  G.  Steinheil, 
1904. 


520  TREATMENT   OF   URINARY  FISTULAS 

membrane  is  excised,  thus  creating  a  vesico-vaginal  fistula,  in 
the  form  of  a  very  elongated  ellipse  into  which  opens  the  ureter, 
at  its  supero-external  angle.  The  wound  is  then  united. 

Pozzi, *  in  a  case  of  lateral  fistula  of  the  ureter,  has  employed  the 
method  of  splitting.  After  having  passed  a  ureteral  catheter,  he 
made  a  transverse  incision  at  the  level  of  the  fistula ;  at  the  extrem- 
ities of  this  transverse  he  made  two  longitudinal  incisions,  giving 
to  the  whole  the  appearance  of  an  H  lying  on  its  side  ( W  ) .  After 
having  cut  the  two  flaps  thus  circumscribed,  he  brought  them  in 
contact  and  sutured  the  one  to  the  other  without  the  least  diffi- 
culty. 

Mackenrodt,2  whose  method  of  procedure  has  given  a  certain 
number  of  successes,  circumscribed  the  fistulous  opening  by  a 
circular  incision  and  dissected  out  the  extremity  of  the  superior 
end  furnished  thus  with  a  collarette,  wrhich  he  fixed  to  the  vesical 
mucous  membrane  of  the  bladder  after  piercing  it  and  introducing 
the  expanded  end  of  the  ureter.  Then  he  shut  the  vaginal  wound 
by  two  layers  of  sutures. 

Sellheim,  in  a  case  of  bilateral  fistula,  where  the  two  orifices 
opened  into  the  bottom  of  a  tunnel,  made  a  vesico-vaginal  fistula 
at  this  level;  then,  in  a  second  operation,  he  sutured  this  fistula 
to  the  borders  of  a  raised  flap.  The  fistulous  openings  thus 
opened  into  a  small  vaginal  diverticulum  in  communication  with 
the  bladder.  Segond  did  a  similar  operation,  fixing  to  the  re- 
freshed border  of  the  vaginal  fistula  a  flap  cut  from  the  base 
of  the  bladder. 

II.  Ureteral  Grafting. 

During  the  last  few  years  plastic  operations  have  to  a  great 
extent  been  replaced  by  ureteral  grafting.  Numerous  methods 
of  doing  this  have  been  recommended.3 

The  operation  of  Mackenrodt  that  we  have  described  in 
connection  with  plastic  operations  is,  in  a  way,  intermediate 
between  plastic  operations  and  vaginal  grafting  by  the  vaginal 
route. 

Other  methods  of  vaginal  grafting  have'  been  employed,  but 

1  Pozzi,  Bull,  ei  Mem.  de  la  Soc.  de  Chir.,  Paris,  1887,  T.  XIII,  p.  114. 

2  Mackenrodt,  Zeitsch.  f.  Geb.  u.  Gyn.,  Stuttgart,  1894,  T.  XXX,  p.  310. 

3  Lutaud,  Ur4t6ro-cysto-n<k>stomie,  Th.  de  Paris,  1907. 


FISTULAS  OF  THE   URETER  521 

now-a-days  there  is  a  tendency  to  abandon  all  these  operations 
through  the  vagina  and  to  do  all  cases  of  utero-cysto-neostomy  by 
the  abdominal  route.  This  latter  operation  has  sometimes  been 
done  by  an  extra-peritoneal  route,  but  in  most  cases  the  intra-peri- 
toneal  method  is  to  be  preferred. 

After  a  median  celiotomy  the  ureter  is  sought  for,  and  is 
usually  easily  to  be  found,  as  it  crosses  the  brim  of  the  pelvis,  and 
is  then  followed  downward.  The  peritoneum  over  it  is  incised, 
and  it  is  dissected  out  a  little  so  as  to  render  it  movable ;  then  it 
is  cut  across  above  the  fistula  and  implanted  in  the  bladder,  which 
has  been  forced  up  by  a  metallic  sound. 


FIG.  416. — Relations  of  the  ureter  at  the  brim  of  the  pelvis. 

An  incision  of  a  centimeter  and  a  half  is  made  in  the  bladder. 
A  loop  of  catgut  having  been  passed  through  the  ureter,  at  a 
certain  distance  from  its  section,  its  ends  are  taken  and  one  is 
threaded  on  a  needle  and  passed  through  the  bladder  wall  from 
within  outward  at  one  extremity  of  the  incision  into  the  bladder; 
then  the  other  end  is  similarly  passed  through  the  other  end  of 
the  incision,  then  by  drawing  on  each  end  the  ureter  is  invaginated 
into  the  bladder  (Fig.  418).  In  order  to  insure  the  free  flow  of 
urine,  a  snip  should  be  made  in  the  wall  of  the  ureter  opposite 
that  carrying  the  loop  of  catgut.  The  bladder  is  then  shut  by 
two  layers  of  sutures  (Fig.  419). 

Ricard  has  operated  recently  in  rather  a  different  manner; 
after  having  split  the  end  of  the  ureter,  he  turns  it  back  like  the 


522 


TREATMENT   OF   URINARY    FISTULAS 


cuff  of  a  coat  sleeve,  and  fixes  the  mucous  membrane  thus 
turned  up  to  the  adventitia  by  two  ligatures  of  fine  catgut  (Figs. 
420  and  421).  He  opens  the  bladder  with  a  bistoury  and  in  the 
small  incision  thus  made  pushes  11/2  to  2  cm.  of  the  ureter 
into  its  cavity.  The  ureter,  of  which  the  extremity  hangs  free 


FIG.  417.— A  loop  of 
catgut  through  the  ureter 
with  the  extremities 
brought  through  the 
bladder  opening  and  out 
again  through  the  wall. 


FIG.  418.  — The 
ureter  drawn  into  the 
bladder  to  be  fixed  by 
knotting  the  ends  of 
the  catgut. 


FIG.  419.— The 
bladder  wall  is  sutured 
round  the  invaginated 
ureter. 


in  the  bladder  like  the  clapper  in  a  bell,  is  fixed  by  a  ring  of 
catgut  sutures  which  pass  through  all  the  layers  of  the  bladder 
wall  save  the  mucous  membrane  on  the  one  side  and  the  external 
and  muscular  walls  of  the  ureter  on  the  other.  A  second  layer 


I 

FIG. 

Uret 
end 

A 

42( 
er  \ 
sp 

\ 

).—      F 
nth      U 
it.         ei 

1  J 

1  f 

[G.  421.— 
reter  with 
id  turned  up. 

of  sutures,  also  of  catgut,  are  placed  above  the  first,  so  as  to 
bring  at  least  one  centimeter  of  the  walls  of  the  bladder  and 
ureter  in  apposition  (Fig.  422). 

Payne1  splits  the  inferior  extremity  of  the  ureter  for  a  length 
of  several  millimeters;  this  forms  two  valves,  which  he  fixes  on 
each  side  of  the  vesical  incision. 


1  Payne,  J.  of  Amer.  Med.  Assoc.,  Chicago,  1908,  p.  1321. 


FISTULAS  OF  THE  URETER 


In  all  cases,  in  order  to  avoid  traction  of  the  bladder  on  the 
ingrafted  ureter,  it  is  advisable  to  fix  the  bladder  to  the  pelvic 
peritoneum  by  a  strong  suture,  attaching  it  in  front  of  the  ureter. 


FIG.  422. — Sagittal  section  of  the  invaginated  ureter. 


III.  Nephrectomy. 

Nephrectomy  is  indicated  when  the  kidney  corresponding  to 
the  fistulous  ureter  is  unhealthy,  showing  signs  of  pyelo-nephritis. 
It  should  only  be  practiced,  however,  if  a  preliminary  examination 
of  the  functional  powers  of  the  other  kidney  shows  this  to  be 
healthy. 


INDEX. 


Abdomen,  inspection  of,  7 

physical  examination  of,  1 
Abdominal  celiotomy,  293 

general  technic  of,  293 
operation  for,  299 
preparatory  measures,  298 
operator,     surroundings,      patient, 

preparation  of  patient,  296,  297 
compresses,  93 
cystopexy,  412 
hysterectomy,  329 

for  cancer  of  the  uterus,  357 
indications  for,  360 
operation  for,  361 
modification  of  operation,  369 
complications,  371 
albuminuria  following,  372 
lesions  of  ureter  following,  372 
results  following,  373 
for  fibroids,  434 
for  fibroma,  349 

indications  for  modification  of  tech- 
nic according  to  the  nature  of  the 
lesion,  347 
for   inflamed  adnexa  and  fibroma, 

349 

results,  349 

extraction  of  fibroma,  350 
indications  for  total    or   subtotal 

hysterectomy,  351 
for  inflammatory  adnexa,  349 
results  of,  349 
type  of  procedure  in,  329 
various  procedures  in,  338 
operations     for     displacements     and 

deviations  of  the  uterus,  393 
some  rare,  407 
myomectomy,  432 
palpation  of  the  ureters,  478 
Absence  of  vagina  without  complications, 

129 

Acid,  leucorrhea,  treatment  of,  121 
Active  electrode,  75 
Acute  adnexitis,  423 

dilatation  of  the  stomach  following 

celiotomy,  325 

Adhesion  of  the  labia,  treatment  of,  107 
of  the  prepuce   of  clitoris,  operation 

for,  106 

Adnexa,  inflammation  of,  381 
neoplasms  of,  382 
removal  of,  378 

treatment  of,  inflammation  of,  422 
removal  of  healthy,  378 
vaginal  hysterectomy  in  inflammation 

of,  265 

Adnexitis,  acute,  423 
chronic,  423 


Amenorrhea,  465 
primitive,  465 
secondary,  466 

use  of  continuous  current  in,  81 
use  of  static  electricity  in,  81 
Amputation  of  the  cervix,  184,  189 
with  the  galvano-cautery,  190 
with  the  knife,  190 
of  clitoris,  110 
Anatomo-pathological  lesion  of  prolapse  of 

the  uterus,  446 

Anatomy  of  the  supports  of  the  uterus,  444 
Anesthesia,  use  of  in  gynecological  exam- 
inations, 18 
Angiotripsy,  260 
Anteflexion  of  the  uterus,  congenital  and 

required,  453 

Nourse  s  operation  for,  195 
Reed's  operation  for,  194 
Anterior  abdominal  hysteropexy,  393 

operation,  393 
results,  396 

indications  for,  398 
colpoceliotomy  of  Doyen,  229 
colporrhaphy,  162 

combination  of,  with  amputation  of 

the  cervix,  167 
precervical,  167 

various  procedures  for,  166 
colpotomy,  219,  233 

immediate  result  of,  230 
incision  of  vagina  in,  220 
modification  of  technic  according  to 

the  case,  222 

opening  of  the  peritoneum,  221 
operative  technic  of,  219 

separation  of  the  bladder  in,  221 
Wertheim-Schauta's,  operation  for, 

227 

Appendix,  18 

Application  of  medicated  bougie  and  of 
caustics  to  the  uterine  cavity,  45 
Atmokausis,  48 

complications  of,  50 
indications  for,  51 
technic  of,  50 
Arcus  Fallopii,  13 
Auscultation,  9 

Baldwin's  resection  of  the  pelvic  colon,  135 
Baldys'  operation  for  shortening  the  round 

ligament,  403 

Bartholinitis,  treatment  of,  104 
Bartholin's  glands,  cysts  of,  117 
Bascule  of  the  uterus,  217 
Benign  tumors  of  the  vulva,  treatment  of 

112 


525 


526 


INDEX 


Beuttncr's     modification     of     abdominal 

hysterectomy,  348 
Bier's  method  for  producing  local  hyper- 

emia,  52 
Bimanual  examination,  11 

with  the  pelvis  elevated,  14,  15 
Bladder,  bimanual  examination  of,  475 

catheterization  of,  475 

curettage  of,  494 

cystoscopy  of,  476 

examination  of,  475 
vaginal,  475 

foreign  bodies  and  calculi  in,  495 

operation  on,  491 

prolapse  of,  wall  of,  497 

surgery  of,  491 

treatment  of,  diseases  of,  495 
Bouilly's  operation,  192 
Bozemann's  catheter,  38 
Broad  ligaments,  ligature  of,  260 
Brusque  dilatation  under  anesthesia,  116 
Budin's  catheter,  38 
Bulb  of  vulva,  99 

Calcium    carbure   in    cases    of   inoperable 

cancer  in,  28 
Canal  of  Nuck,  100 

of  the  urethra,  examination  of,  473 
Cancer  of  the  uterus,  abdominal  hysterec- 
tomy for,  357 

indication    for    abdominal    hysterec- 
tomy in,  360 

involvement  of  glands  in,  358, 
modification  of  the  operation  of   ab- 
dominal hysterectomy  for,  371 
modification  of  the  operation  of  hys- 
terectomy for,  369 
vaginal  hysterectomy  in,  261 
operation  of  hysterectomy  for,  361 
Cancers  of  the  urethra,  490 
Cannulas,  24 
Canquoin's  paste,  45 
Carbon  electrode,  75 
Cataphoresis,  78 
Catarrhal  metritis,  use  of  mineral  water  in 

the  treatment  of,  96 
Catheterization  of  the  ureters,  479 
of  the  urethra,  481 
of  the  uterus,  29 

contraindication  to,  30 
indication  for,  30 
Caustic  pencils,  45 

Caustics,  application  of  to  uterine  cavity,  45 
method  of  application  to  interior  of 

uterus,  46 

Celiotomy,  abdominal,  293 
complication  of,  323 

abscess  of  the  wall  following,  326 
acute  dilatation  of  the  stomach  fol- 
lowing, 325 

eventration  following,  328 
intestinal  occlusion  following,  325 
internal  hemorrhage  following,  323 
late  intoxication  by  anesthesia  fol- 
lowing, 326 

septic  peritonitis  following,  324 
parotitis  following,  325 
phlebitis  following,  327 


Celiotomy,    pulmonary    complications   of, 
326 

pyo-stercoral  fistulas  after,  327 
retention  of  urine  after,  326 
shock  following,  323 
slight  peritonitis  following,  324 
urinary  fistulas  following,  327 
median    and    transverse,    after-treat- 
ment of,  321 
transverse,  320 

Cervical  fibromata,  removal  of,  203 
Cervix,  amputation  of,  184 
with  the  knife,  190 
with  the  galvanocautery  of,  190 
Bouilly's  operation  on,  192 
indication  for  amputation  of,  189 
for  definite  occlusion  of,  177 
for  temporary  occlusion  of,  177 
infra  vaginal  amputation  of,  184 
occlusion  of,  177 
one  flap  amputation  of,  186 
Powey's  operation  on,  192 
position  of  as  found  in  vaginal  exami- 
nation, 10 
scarification  of,  192 
supra  vaginal  amputation  of,  189 
the  two  flap  amputation  of,  185 
various  operations  on,  192 
Cestokausis,  52 
Chancre  of  the  vulva,  111 
Choice  of  operation  in  pregnancy,  compli- 
cated by  uterine  fibroids,  435,  436 
Chronic  adnexitis,  423 

conservative  treatment  of,  424 
surgical  treatment  of,  427 
metritis,  treatment  of,  418 
general,  420 
local,  417 

cauterization  in,  418 
curettage  in,  419 
vaginal  dressings  in,  418 
Cicatricial  constriction,  treatment  of,  108 
Cicatricial  constriction,  treatment  of,  108 
Circular  friction,  89 
Clitoris,  removal  of,  110 
Colpectomy,  169 
Colpoclesis,  514 
Colpocystostomy,  493 
Colpoperineoplasty,  Doleris',  151 
Colpoperineorrhaphy,  142 

by  division  and  splitting,  151 
by  resection,  142 

Colporrhaphy,  anterior  perineal,  167 
Colpotomies,  213 
Colpotomy,  anterior,  219 

indication  for,  anterior,  233 
posterior,  213 
result  of,  230 

Combination    of    anterior    colporrhaphy, 
with  amputation  of  the   cervix, 
167 
Complete  central  rupture  of  the  perineum, 

141 
Complete  rupture  of,  156 

tear  of  the  perineum,  156 
Complications  in  the  use  of  pessaries,  58 
of  celiotomy,  323 
to  uterine  curettage,  65 


INDEX 


Congestive  metrorrhagia  of  puberty,  use  of 
mineral  water  in  the  treatment 
of,  96 
Conservative  operation,  353 

on  the  ovary,  389 
Constriction    of    the    vagina    by    metallic 

sutures,  168 

Freund's  method  of,  168 
Continuous  irrigation,  40 

of  the  uterus,   complications  arising 

during,  42 

Contusions  of  the  vulva,  treatment  of,  101 
Courty's  operation,  179 
"Cri  uterine,"  63 
Crucial    incision  of    the   cervix,  Fritsch's 

incision,  178 
Cuneohysterectomy,  404 
Curative  treatment  of  fistulas  of  the  ureter, 

519 

of  metritis,  415 
Curettage  of  the  bladder,  494 

of  the  uterus  apart  from  the  puerperal 

state,  70 
indication  for,  68 

in  the  puerperal  state,  68 
Curetting  of  the  uterus,  60 

of  the  uterus  as  a  curative  agent,  71 
exploratory,  70 
for  puerperal  metritis,  416 
in  cancer,  71,  72 
hemorrhage  following,  66 
Cuscos'  speculum,  16 
Cutaneous  tumors  of  the  vulva,  112 
Cystoscopy,  476 
Cystitis,  496 
Cysts  of  Bartholin's  glands,  113 

of  the  vagina,  treatment  of,  123 


David's  hysteroscope,  21 

Deep  inflammatory  lesion,  treatment  of, 

104 
Definite  occlusion  of  the  cervix,  indication 

for,  177 
Denudation  by  splitting  outward  from  the 

fistula,  506 

De  Pezzer's  catheter,  505 
Dilatation  of  the  urethra,  481 

of  the  uterus,  31 
Dilator  with  three  blades,  32 
with  transverse  groove,  32 
with  two  blades,  32 

Direct  obliteration  of  vesico-uterine  fistu- 
las, 514 
Diseases  of  the  bladder,  treatment  of,  495 

of  the  urethra,  treatment  of,  489 
Displacements  and  deviation  of  the  uterus, 

abdominal  operation  for,  393 
of   the   uterus   as   diagnosticated   by 

bimanual  examination,  11 
Division  of  the  vulvo-vaginal  tissues,  108 
Dobourg's,  procedure  of,  169 
Doleris'  brush,  65 
catheter,  38 
colpoperineoplasty,  151 
Doyen's  anterocolpoceliotomy,  229 

hemisection  of  the  uterus  in  vaginal 
hysterectomy,  243 


Doyen's   operation   for   vaginal   hysterec- 
tomy for  prolapse,  269 

for  recto- vaginal  fistula,  172 
vaginal  hysterectomy,  256 
Drainage  of  uterus,  47 
Dudley  s  operation,  402 
Duhrssen's    method    of    fixation    of    the 

uterus,  224 
Dumontpallier's  pessary,  55 

Eczema  of  vulva,  treatment  of,  103 
Electrode,  active,  75 

carbon,  75 
Electrodes,  74 
Electrolytic  introduction  of  metallic  ions, 

78 
Electrotherapeutics  as  a  means  of  treating 

metritis,  84 
motor  action,  79 
indications  for,  81 
X-rays  in,  80 
Electrotherapy,  73 

chemical  action  in,  76 
instruments  for,  73 
Elevation,  89 

Elephantiasis  of  the  vulva,  112 
Episiorrhaphy,  107 
Epithelioma  of  uterus,  treatment  of,  438 

of  the  vulva,  114 

Erythrasma  of  vulva,  treatment  of,  103 
Eversmann's  cupping  apparatus,  53 
Exaggerated  mobility  of  the  uterus,  452 
Examination  of  the  bladder,  475 
of  the  kidneys,  479 
of  patient  suffering  from  sterility,  469 
of  the  ureters,  478 
of  the  urine,  472 
with  the  speculum,  15 
Excision  of  the  hymen  and  of  the  vaginal 

entrance,  116 
of  inflammatory  lesions  of  the  vulva, 

111 

of  labia  minora,  106 
Excrescences  of  the  urethra,  489 
Exploratory  curettage  of  the  uterus,  70 
Extensive  anterior  colporrhaphy  for  colpo- 

cystocele,  163 

External  genitalia,  inspection  of,  9 
Extrauterine  pregnancy,  460 

after  fifth  month,  management  of, 
when  fetus  is  living  or  viable,  462, 
463 

after  five  months'  management  of.  in 
cases  when  the  fetus  is  dead,  463 
complication  in  the  evolution  of,  460 
expectant  treatment  in,  461 
necessity  of  operating  on,  461 
observed  in  the  course  of  the  first 

five  months,  461 
removal  of  gravid  tube  in,  461 
treatment  of  after  five  months,  462 
Extrauterine   symptoms  in  gynecological 
conditions,  5 

Failures  in  curettage  of  the  uterus,  67 
Faure's,  J.  L.,  procedure  in  vaginal  hys- 
terectomy, 259 
Fedorow's  operation  on  the  vagina,  135 


528 


INDEX 


Fergusson's  cylindrical  speculum,  16 
Fibromyoma  of  the  vagina,  treatment  of, 

123 
Fibromata  and  myomata   of  the  urethra, 

489 

hysterectomy  for  gangrenous,  353 
01  the  uterus,  removal  by  the  vaginal 

route,  202 

vaginal  hysterectomy  in,  263 
Filho's  bougies,  46 

polypus,  removal  of,  202 
Finger,  use  of  as  an  aid  in  curettage  of  the 

uterus,  68 
Fistula,    operative  treatment  for   vesico- 

vaginal,  501 
Fistulas,  preoperative  treatment  of  vesico- 

vaginal,  500 

treatment  of  urinary,  498 
vesico-uterine,  514 

direct  obliteration  of,  514 
indirect  obliteration  of,  515 
of  the  ureter,  518 
uretero-vaginal    with    destruction    of 

the  urethra,  515 
Flap-splitting  operation  in  vesico-vaginal 

fistula,  506 
Folding  up  and  fixation  of  the  tubes  to  the 

anterior  wall  of  the  uterus,  402 
of  the  round  ligament  and  fixation  of 
the  fold  to  the  posterior  surface 
of  the  uterus,  403 
Foreign  bodies  in  the  vagina,   treatment 

of,  120 

and  calculi  in  bladder,  495 
and  calculi  in  the  urethra,  487 
Formation  of  a  neo-vagina,  129 
Fortsch's  operation,  226 
Fourchette,  98 
Freund's   method   of   constriction   of   the 

vagina,  etc.,  168 

Fritsch  and  LeDentu's  operation  for  recto- 
vaginal  fistula,  174 
Fritsch's  operation  for  crucial  incision  of  the 

cervix,  178 
procedure  for  vaginal  prolapse,  267 

Galvanocautery,  260 

Gangrenos  fibromata,    hysterectomy    for, 

353 

Gaull's  air  pessary,  54 
General  anatomy    of  the   uterine  artery, 

198 

considerations  in  gynecological  diag- 
nosis, 1 
indications  for  treatment  in  uterine 

prolapse,  450 

technic  of  abdominal  celiotomy,  293 
plastic  operation  on  the  perineum  and 

vagina,  136 

Genital  examination,  9 
prolapse,  444 

operative  treatment  of,  449 
Gerard    Marchand's    operation  for  recto- 
vaginal  fistulas,  174 
Gersurry's  operation  on  vagina,  135 
Glands  of  Bartholin,  99 

treatment  of  inflammation  of,  104 
vulvovaginal,  99 


Gonorrheal  metritis,  416 

vaginitis,  treatment  of,  121 
Gradual  dilatation  of  the  uterus,  instru- 
ments required  in,  34 
Gynecological    diagnosis,    examination   of 

abdomen  in,  7 
interrogation  in,  7 
physical  examination  in,  6 
significance  of,  absence  or  variation 

in  menstruation,  2 
pain  in,  4 
swellings  in,  4 
vaginal  discharges  in,  3 
value  of  symptoms  in,  5 

Hegar's  bougie,  32 

procedure  for  laceration  of  the  peri- 
neum, 150 

urethral  bougies,  482 
Hematoma  of  the  vagina,   treatment  of, 

120 
Hemorrhage,  significance  of  as  a  symptom, 

3 

following  curettage  of  the  uterus,  66 
Hemorrhagic  metritis,  420 
Hepner's  operation,  131 
Hodge's  pessary,  55 
Hydromineral  treatment,  94 
Hydronephrosis  as  diagnosticated  by  bi- 

manual  examination,  15 
Hydrotherapy,  93 
Hymen  and  vaginal  entrance,  excision  of, 

116 
Hysterectomy,  abdominal,  329 

indication  for,  and  modification  of 
technic  according  to  the  nature  of 
the  lesion,  347 
for  inflammatory  diseases  of  adnexa, 

347 

by  continuous  transverse  section,  341 
for  gangrenous  fibromata,  353 
for  included  fibroids,  352 
by  the  paravaginal  route,  273 

circular  separation  and  closing  the 

vagina,  275 

closing  of  the  peritoneum,  etc.,  280 
dissection  of  the  bladder  and  ureter, 

277 

freeing   the   lateral  borders  of   the 
vagina  and  dissection  of  base  of 
parametrium  in,  278 
history  of,  273 
opening  of  the  peritoneum,  removal 

of  uterus  and  vagina  in,  279 
operation,  274 
paravaginal  excision,  276 
results  and  indications  in,  281 
by  primary  excision  of  the  uterus,  341 
for  prolapse,  375 
in  puerperal  infection,  266 
for  puerperal  septic  infection,  417 
by  separation,  338 
subtotal,  334 
total,  336 

by  uterine  hemisection,  343 
for  uterine  rupture,  376 
vaginal,  235,  433 

for  cancer  of  the  uterus,  261 


INDEX 


529 


Hysteropexy,  anterior  abdominal,  393 
Hysterophores,  54 
Hysteroscope,  21 
Hysteroscopy,  20 
Hysterotomy,  29 

Immediate  perineorrhaphy,  139 

Imperforate  hymen,  operation  for,  17 

I mperf oration  of  the  vagina,  operation  for, 

133 

Incomplete  rupture  of  the  perineum,  140 
Incomplete  perineal  tears,  151 
Incontinence    of    urine,    anterior    colpor- 

rhaphy  as  a  cure  for,  485 
Duret's  operation  for,  485 
Fritsch's  operation  for,  485 
Gersuny's  operation  for,  485 
Hofmeier's  operation  for,  486 
operation  for,  484 
Pawhin's,  operation  for,  485 
Pousson's  operation  for,  485 
Indications  for  abdominal  hysterectomy  in 

cancer  of  the  uterus,  360 
and    modification    of    technic    ac- 
cording   to    the    nature    of    the 
lesions,  347 

for  amputation  of  the  cervix,  189 
for  anterior  colpotomy,  233 
and  contraindication  to  intra-uterine 

douching,  43 
to  massage,  92 
to  vaginal  douches,  26 
for  currettage  of  the  uterus,  68 

in  the  puerperal  state,  68 
for  ligature  pi  the  uterine  arteries  by 

the  vaginal  route,  201 
for  operations  for  recto- vaginal  fistula, 

176 
for  supra  vaginal  amputation  of  the 

cervix,  191 

for   tamponing  the  vagina,  28 
for  temporary  occlusion  of  the  cervix, 

177 

for  use  of  electrotherapeutics,  81 
to  the  use  of  pessaries,  59 
Indirect  hysteropexy,  398 
operation,  400 
indications  and  results,  400 
obliteration  of  vesico-uterine   fistula, 

515 
Infection     following     currettage     of     the 

uterus,  66 
Infibulation,  107 
Inflammation  of  the  adnexa,  381 
indications,  381 
operation,  381 

Inflammatory  lesions,  excision  of,  111 
of  the  vagina,  treatment  of,  121 
of  the  vulva,  treatment  of,  102 
Infra  vaginal  amputation  of  the  cervix,  184 
Injections,  intrauterine,  44 
Inoperable  cancer  of  the  pregnant  uterus, 
1    treatment  of,  441 
Inspection,  7,  9 
Instruments  for  electrotherapy,  73 

required    in    rapid    dilatation    of   the 

uterus,  31 
Insufflating  bag,  54 
34 


Internal  pudic  nerve,  resection  of,  117 
urethrotomy,  indications  for,  483 
Interrogation,  1,  2 

of  patient  suffering  from  disease  of  the 

genito-urinary  system,  471 
Interstitial  myomata,  conservative  opera- 
tion for,  354 
Intestinal  hemorrhage  following  celiotomy, 

323 

Intestine,  transplantation  of,  134 
Intra-abdominal  shortening  of  the  round 

ligaments,  400 

of  the  utero-sacral  ligaments,  406 
Intra-uterine  application  of  electricity,  77 
douche,  40 

douching,     indications     and  '  contra- 
indication, 43 
injections,  44 

accidents  arising  from,  45 
irrigation,  416 
lavage,  37 

in  the  non-puerperal  state,  43 
in  the  puerperal  state,  37 
in     the     puerperal     state,    instru- 
ments required,  37 
in  the  puerperal  state,  technic  of,  39 
medication,  37 
Introduction  of  fluid  or  air  into  the  veins 

during  intra-uterine  douche,  42 
Irrigating  curette,  64 
Irrigation,  continuous,  40 
Instruments  for  vaginal  injection,  22 
Inversion  of  the  puerperal  uterus,  457 

of  the  uterus,  457 
Isaac's  operation,  132 

Jacobs'  ligamentary  trachelopexy,  450 
Jayle's  bivalve  speculum,  16 
Juxta-uterine    tumors,    vaginal    hysterec- 
tomy for,  271 

Kelly's  conical  dilator,  478,  482 

operation  for  colpocystotomy,  493 
Kidneys,  examination  of,  479 
Kinetotherapy,  88 
Knee-elbow  position,  20 
Kraske's  operation  for  perineotomy,  284 
Kraurosis,  treatment  of,  105 

Labia  majora,  blood  supply  of,  100 
lymphatics  of,  101 
minora,  excision  of,  106 
treatment  of  adhesion  of  the,  107 
Laceration  of  perineum,  treatment  of,  138 
Late  perineorrhaphy,  141 
Lefour's  tube,  48  , 

Left  lateral  position,  19 
Leucoplasia,  treatment  of,  105 
Leucorrheal  form  of  metritis,  420 
Ligature  of  the  broad  ligaments,  260 
of  the  hypogastric  veins,  411 
extraperitoneal  route,  411 
transperitoneal  route,  411 
of  the  uterine  arteries  by  the  vaginal 

route,  198 
by   the   vaginal   route,   indications 

for,  201 

by    the    vaginal    route,    operative 
technic  of,  2UO 


530 


INDEX 


Ligature  of  the  uterine  artery  by  the  ab- 
dominal route,  409 

across  the  broad  ligaments,  410 
at  the  level  of  the  ovarian  fossa,  409 
Leguen's      operation      for      recto-vaginal 

fistula,  176 
Lithotrity,  494 
Local  hyperemia,  apparatus  for  producing, 

52 

Lupus  of  the  vulva,  111 
Lymphangitic  abscess,  treatment  of,  104 

Mackenrodt's  operation  for  uteral   fistula, 

520 
Malaxation  or  kneading,  90 

of  the  vulva,  114 
Malignant  tumors  of  the  vagina,  124 

of  the  uterus,  436 

chemical  caustics,  438 
epithelioma,  438 
removal  of  uterus  for,  437 
treatment  of  sarcoma  of,  437 
use  of  X-ray  in,  438 
Massage,  89 

indications  and  contraindications,  92 
Median  celiotomy,  299 

abdominal  incision  in,  301 

closing  the  abdominal  wall  in,  308 

different  methods  of  suture,  312 

drainage  in,  315 

dressing  of,  318 

examination  of  the  appendix  in,  308 

hemostasis,  307 

lavage  of  the  peritoneum  in,  318 

limitation  of  the  operative  field  in,  303 

preliminaries  of  the  operation,  299 

treatment  of  adhesions  in,  305 
Menopause,  troubles  of,  468 
Menorrhagia  and  metrorrhagia,  466 

definition  of,  3 

significance  of  as  a  symptom,  3 
Menstrual  troubles  and  sterility,  465 
Menstruation  changes  in  as  a  symptom  of 
disease,  2 

supplementary,  466 

troubles  of,  465 

Method  of  genital  examination,  9 
Metritis,  acute,  treatment  of,  416 

causes  of,  414 

hemorrhagic,  420 

gonorrhea!,  416 

leucorrheal  of,  420 

septic,  416 

treatment  of,  413 
curative,  415 
prophylactic,  415 

use  of  electricity  in  the  treatment  of,  84 
Metrorrhagia,  definition  of,  3 

occurring  at  menopause,  use  of  min- 
eral water  in  the  treatment  of,  96 

significance  of,  3 
Michaux,  procedure,  109 
Minor  gynecology,  22 
Mobile,  retrodeviation  of,  454 
Molimen  without  menstrual  retention,  129 
Morcellement,  210 
Movements,  90 

increasing  congestion,  91 


Movements,  lessening  congestion,  90 
Mucous  vulvitis,  treatment  of,  103 
Mud  baths,  95 
Muller's    method    for    total    removal    of 

vagina,  171 

Myomata  conservative  operation  for  re- 
moval of  interstitial  variety,  354 
pediculated,     conservative    operation 

for,  354 

Myomectomy,  abdominal,  for  uterine  fib- 
roids, 432 

morcellement  for,  210 
transvaginal,  202 
transvagino-uterine,  204 

Neoplasms  of  the  adnexa,  treatment  of,  382 

adhesions,  385 

included  cysts,  385 

extirpation  of  small  growths.  382 

operation,  382 

operative  complications,  385 

removal  of  large  cystic  tumors,  382 
use  of  electrotherapeutics  in,  88 
Neo vagina  formation  of,  129 
Nephrectomy,  523 

Nervous  dysmenorrhea,  use  of  static  elec- 
tricity in,  81 
Nourse's  operation  for  anteflexion  of  the 

uterus,  195 
Nymphorrhaphy,  107 

Obliteration  of  the  pouch  of  Douglas,  407 
of  the  uterine  cavity  following  curet- 

tage  of  the  uterus,  67 
Occlusion  of  the  cervix,  177 
Old  complete  perineal  tears,  142 

and  complete  tears  of  the  perineum, 

148 
tears    of    perineum    complicated    by 

prolapse,  149,  158 

One-flap  amputation  of  the  cervix,  186 
Oophorectomy,  380 
Operation  for  enlarging  the  vulvar  orifice, 

107 

on  the  bladder,  491 
on  the  cervix  and  pregnancy,  195 
constricting  or  closing  the  vulva,  107 
from  incontinence  of  urine,  484 
for  rectovaginal  fistula  by  the  perineal 

rout,  174 

for  rectovaginal  fistula  by  the  vagi- 
nal route,  171 
for  rectovaginal  fistula  by  the  vagino- 

perineal  route,  176 
on  the  tubes  and  ovaries,  378 
on  the  urethra,  481 
on  the  urinary  apparatus,  471 
for  uterine  flexions,  193 
for  vesicovaginal  fistula,  501 
on  the  vulva,  106 
Operative   modification  according  to  the 

nature  of  the  lesion,  261 
technic    of    ligature    of    the    uterine 
arteries  by  the  vaginal  route,  200 
treatment  of  cancer  of  the  uterus,  361 
treatment  of  prolapse  of  the  uterus,  449 
Organic  lesions,  use  of  electrotherapeutics 
in,  82 


INDEX 


531 


Ovariopexy,  390 

Ovarian  cysts,  removal  of  layer,  382 

grafts,  391 
Ovary,  conservative  operation  on,  389 

tumors  of,  442 

in  pregnant  women,  443 

Pain  as  a  general  symptom  in  gynecologi- 
cal conditions,  4 
Palliative  treatment  of  inoperable  cancer 

of  the  vagina,  125 
of  uterine  fibromata,  430,  431 
electricity  in  the,  431 
use  of  X-ray  in,  431 
palliative  medical  treatment,  430 
Palpation,  7 

Papillary  cysts,  removal  of,  442 
Paravaginal  route,  hysterectomy  by  the, 

273 

Pasteau's  straight  urethrotome,  482 
Patient  in  position  for  curretting  of  the 

uterus,  62 

Payne's  operation  for  ureteral  fistula,  522 
Pean  and  Segoud's  hysterectomy,  205 
Pean's  hysterectomy,  256 
Pediculated  myomata,  conservative  opera- 
tion for,  354 
Pelvis,  vertical  and  transverse  section  of, 

100 
Penetration  of  fluid  into  the  peritoneum, 

42 

Percussion,  7 
Perforation  of  the  uterus  during  curettage, 

66 
of    the  uterus   from  introduction  of 

catheter,  42 
Perineal  lacerations,  prevention  of,  138 

treatment  of,  138 
Perineal    and  sacral  routes,  perineotomy 

by  the,  282 
section,  491 
tears  (old),  142 
Perineorrhaphy,  colpo-,  142 
immediate,  139 
late,  141 
secondary,  141 
Perineotomy,  282 

operation  of  Hochenegg,  284 
operation  of  Roux,  284 
by  parasacral  route,  283 
by  sacral  route,  283,  284 
sagittal,  283 
transverse,  282 

Perineum,  complete  tears  of,  156 
incomplete  tears  of,  151 

rupture,  140,  141 
Hegar's  procedure  for  laceration  of, 

150 
old  and  complete  tears  of,  148 

tears  of,  complicated  by  prolapse, 

148,  158 

Tate's  procedure  for  laceration  of,  151 
and  vagina,  136 

Veit's  procedure  for  repair  of  lacera- 
tion of,  148 

Peritoneum,  penetration  of  fluid  into,  42 
Periurethral  malignant  tumors,  490 
Pessaries,  53 


Pessaries,  complication  in  the  use  of,  58 
indication  to  the  use  of,  59 
mode  of  introduction  and  details  to 

observe.  56 
use  of  in  retrodeviation  of  the  uterus, 

455 

vaginal,  54 
vagino-abdominal,  54 
various  types,  53 
Pessary,  Dumontpallier's,  55 
Gaull's  air,  54 
Hodge's  55 

Schultze,  figure-of-8,  55 
Schultze's  sledge-formed,  56 
Pestalozza's  operation,  405 
Petit's  drain,  48 

Phlebitis  following  celiotomy,  327 
Physical  examination,  6 
Physiological  bases,  73 
Pinard's  catheter,  37 
Pincus  apparatus,  49 
Plastic  occlusion  of  the  ureter,  519 

operation  on  the  hymen  and  vaginal 

entrance,  116 
on  the  perineum  and  vagina,  136 

general  technic  of,  136 
Polypoid  inversion,  458 
Positions  of  patient  taking  a  vaginal  douche, 

24 

Posterior  colpotomy,  213 
indications  for,  216 
operation,  213 
results  of,  216 

Postoperative  details  of  vaginal  hysterec- 
tomy, 250 

Pouch  of  Douglas,  obliteration  of  the,  407 
Pouey's  operation,  192 
Pozzi's  operation,  181 

for  ureteral  fistulas,  520 
sound, 137 
Pregnancy  complicated  by  uterine  cancer, 

440 

extrauterine,  460 
Preliminary  creation  of  means  of  access, 

204 
Preoperative  treatment  of  urinary  fistulas, 

500 

of  vesico-vaginal  fistulas,  500 
Prepuce  of  clitoris,  operation  on,   106 
Pressure,  89 

Primitive  amenorrhea,  465 
Principal    mineral   waters   used   in   gyne- 

cology,  94 

Prismatic  cystoscope,  476 
Probes  for  applying  caustics,  47 
Procedure  of  Dubourg,  169 
Procedures  of  Quenu  and  Muller,  258 
Prolapse  of  the  uterus,  444 

hysterectomy  for,  375 
Marion's  operation  of   obliteration 
of  the  pouch  of  Douglas  for  the 
cure  of,  407 

operative  treatment  of,  449 
of  the  urethral  mucous  membrane,  489 
of  vesical  mucous  membrane,  497 
Proliferating  urethritis,  488 
Prophylactic    medical   treatment   of   pro- 
lapse, 448 


532 


INDEX 


Prophylactic  medical  treatment  of  fistulas 

of  the  ureter,  519 
of  metritis,  415 
of  vesico-vaginal  fistulas,  499 
Pruritis  vulvae,  treatment  of,  105 
Puerperal  infection,  hysterectomy  in,   266 
inversion,  457 

septic  infection,  hysterectomy  for,  417 
state,  intrauterine  lavage  in,  37 
Pulmonary  complications  following  celiot- 

omy,  326 

Pyostercoral  fistulas  following  celiotomy, 
327 

Radical  treatment  of  uterine  fibroids,  432 
Rapid  dilatation  of  the  uterus,  31 

instruments  required  in,  31 
Rectal  examination,  15 
Rectovaginal  fistula,  indication  for  opera- 
tion for,  176 

operations  by  the  vaginal  route,  171 
by  periheal  route,  174 

by  the  vaginoperineal  route,  176 
Sanger's  operation  for,  172 
Doyen's  operation  for,  172 
Fritsch  and  Le  Dentu's  operation  for, 

172 

Schauta's  method  for,  171 
treatment  of,  171 
Reduction    of    uterine    inversion    by    the 

abdominal  route,  412 
Reed's   operation   for   anteflexion   of   the 

uterus,  194 

Removal  of  the  adnexa,  378 
of  clitoris,  110 
of  cervical  fibromata,  203 
of  fibrous  polyps,  202 
of  fibromata  by  the  vaginal  route,  202 
of  healthy  adnexa,  378 
operation,  378 
indication  for,  379 
of  healthy  ovary  in  cases  of  ovarian 

cyst,  443 

Resection  of  the  internal  pudic  nerve,  117 
Retrodeviations  of  the  uterus,  453 

use  of  pessaries  in,  455 
Retroflexion  of  the  gravid  uterus,  456 
Ricard's  operation  for  urethral  grafting, 

521 

Ring  curette,  63 
Rochert's  modification  of  colpocystotomy, 

493 

Rosrier's  operation,  180 
Round  ligaments,  folding  up  for  the  fixation 
of  the  fold  to  the  posterior  surface 
of  the  uterus,  403 
of  the  uterus,  403 
folding  up  and  fixation  to  the  anterior 

surface  of  the  uterus,  402 
intraabdominal  shortening  of,  400 
shortening  of,  in  the  inguinal  canal,  286 
simple  folding  of,  401 

Rudolph,  J.,  apparatus  for  producing  ther- 
mic action  in  local  hyperemia,  52 
Rules  for  introduction  of  catheter  into  the 

uterus,  40 

Rupture  of  the  uterus,  hysterectomy  for, 
376 


Sanger's  operation  for  recto- vaginal  fistul  a 

172 

sagittal  perineotomy,  283 
Sarcoma  of  uterus,  treatment  of,  437 
Scarification  of  the  cervix,  192 
Schauta's  method  of  operation  for  recto- 
vaginal  fistula,  171 
Schroder's    one-flap    amputation    of    the 

cervix,  186 
Schultze's  figure-of-8  pessary,  55 

sledge-formed  pessary,  56 
Schwartz  operation,  134 
Sclerous  urethritis,  489 
Sebaceous  vulvitis,  treatment  of,  103 
Secondary  amenorrhea,  466 

perineorrhaphy,  141 
Segond's  operation,  257 

resection  for  recto- vaginal  fistulas,  174 
Sellheim's  operation  for  ureteral  fistulas, 

520 
Septic  metritis,  416 

peritonitis  following  celiotomy,  324 
Shock  following  celiotomy,  323 
Shortening  of  the  round  ligaments  in  the 
inguinal  canal,  anatomical  recap- 
itulation, 286 
operative  technic,  287 
various  modifications  of  operation 

for,  290 
results  and  indications,  291 

region,  286 

of  the  uterosacral  ligament,  218 
Simon-Marckwald's    two-flap    amputation 

of  the  cervix,  185 

Simple  denudation  operation  for  vesico- 
vaginal  fistulas,  503 
folding  of  the  round  ligaments,  401 
inspection  of  the  urethra,  473 
Sim's  duckbill  speculum,  16 

method  of  introducing,  19 
position,  19 
Sismotherapy,  93 
Slow  dilatation  of  the  uterus,  indications 

for,  36 

or  gradual  dilatation  of  the  uterus,  34 
Some  rare  abdominal  operations,  407 
Special  procedures  in  operation  for  vesico- 
vaginal    fistulas,     applicable     to 
large  losses  of  substance,  511 
flaps,  511 

Fritsch  operation,  511 
Trendelenberg's  suture,  511 
Odenthal's  modification,  511 
operation  in  stages,  512-513 
Speculum,  Cusco's,  16 
examination  with,  15 
Fergusson  cylindrical,  16 
method  of  introducing,  16,  27 
manner  of  removing,  17,  18 
Jayle's  bivalve,  16 
Sim's  duckbill,  16 

Speculums,  varieties  of  dicusped,  15,  16. 
Spinelli's  operation,  229 
Splitting  of  the  anterior  wall  of  the  vagina 
and  sutures  of  the  levatores  ani 
muscles,  168 

outward  from  an  incision  at  a  distance 
from  the  fistula,  507 


INDEX 


533 


Standing  position,  19 
Stenosis  of  the  vagina,  126 
Sterility,  469 

treatment  of,  470 
Stricture  and  obliteration  of   the  uterine 

cavity    following     curettage    of     the 

uterus,  67 

Stomatoplasty,  Pozzi's,  181 
Stroking,  90    - 

Stricture  and  atresia  of  the  vagina,  125 
Subcutaneous  tumors  of  the  vulva,  113 
Subtotal  hysterectomy,  334 
Suburethral  abscess,  489 
Supplementary  menstruation,  466 
Supra  vaginal  amputation  of  the  cervix,  189 

indication  for,  191 
Surgery  of  the  Bladder,  491 

of  the  urethra,  481 

of  the  vagina,  119 

of  vulva,  98 
Swellings,  4 

causes  of,  4 

Tait's  procedure  for  repair  of  laceration  of 

perineum,  151 

Tamponing  of  the  vagina,  28 
Tampons,  7 

Technic  of  intrauterine  lavage  in  the  puer- 
peral state,  39 
of    instrumental     dilatation    of    the 

uterus,  31 

of  vagina!  irrigation,  24 
Tenaculum  forceps,  62 
Tents,  technic  of,  introducing,  35 

technic  of  removal  of,  36 
Therapeutic  indications  in  disease  of  the 

genital  system  of  woman,  413 
for  mineral  waters,  96 
Thiersch's  grafts,  132 
Thiriar    and    Jonnesco's    anterior    cuneo- 

hysterectomy,  404 
Total  hysterectomy,  336 

by  subperitoneal  dicortication  with 
primary  opening  of  the  posterior 
fornix  and  with  preliminary  hemo- 
stasis,  345 

Trachelorrhaphy,  182 
with  flaps,  184 
with  surface  denudation,  183 
Trachelotomy,  178 

Courty's  operation  for,  179 
Pozzi's,  181 
Ressner's,  180 

Transplantation  of  the  intestine,  134     < 
Transvaginal  myomectomy,  212 
Transvagino-uterine  myomectomy,  204 
after-treatment  of,  212 
indications  for,  212 
suture  of  the  cervix  after,  211 
treatment  of   sites   occupied   by   the 
tumors  and  of  the  uterine  cavity 
after,  211 
Transverse  celiotomy,  320 

perineotomy,  282 
Treatment  of  benign  tumors  of  the  vulva, 

112 

of  chronic  metritis,  418 
of  cystitis,  496 


Treatment  of  cysts  of  the  vagina,  123 
of  deep  inflammatory  lesions,  104 
of  diseases  of  the  bladder,  495 

of  the  urethra,  487 
of  dysmenorrhea,  467,  468 
of  early  extrauterine  pregnancy,  416 
of  extrauterine  pregnancy  after  the 

fifth  month,  462 

of  fibromyoma  of  the  vagina,  123 
foreign  bodies  in  the  vagina,  120 
of  fistulas  of  the  ureter,  518 

situated  in  the  neighborhood  of  the 

cervix  uteri,  509 
operation  of  the  above  in  several 

stages,  509 

of  gonorrheal  vaginitis,  121 
of  inflammation  of  the  adnexa,  422 
of  malignant  tumors  of  the  vagina,  124 
of  hematomas  of  the  vagina,  120 
of  inflammatory  lesions  of  the  uterus 

and  adnexa,  413 
of  the  vagina,  121 
of  inversion  of  the  puerperal  uterus, 

457 
of  menorrhagia  and  metrorrhagia,  446, 

467 

of  metritis,  413 
of  acute,  415 
of  gonorrheal  416 
of  septic,  416 
of     neoplasms     of    the     uterus     and 

adnexa,  429 
of  operable  cancer  at  time  of  accouch- 

ment,  441 

in  early  pregnancy,  440 
of  perineal  tears,  138 
of  polypoid  inversion,  458 
of  primary    and    secondary  amenor- 

rhea,  465,  466 

of  recto-vaginal  fistulas,  171 
of  stenosis  of  the  vagina,  126 
of  sterility,  470 
of  stricture  and  atresia  of  the  vagina, 

125 

of  traumatic  lesions  of  the  vagina,  119 
of  troubles  of  the  menopause,  468,  469 
of  tumors  of  the  vagina,  123 
of  urinary  fistulas,  498 
of  uterine  deviations,  451 
.  fibroid  in  pregnancy,  434 
cancer  in  pregnancy,  440 
inversions,  218 

of  utero-vaginal  fistulas  with  destruc- 
tion of  the  urethra,  515 
of  vaginitis,  121 
of  vesicovaginal  fistula,  500 
of  wounds  of  the  vulva,  101 
Tripier's  hollow  dilator,  482 
Troubles  of  the  menopause,  468 

of  menstruation,  465 
Tubes  and  ovaries,  operation  on,  378 
Tumors  of  the  ovary,  442 

and  pregnancy,  443 
of  the  urethra,  489 
Two-flap  amputation  of  the  cervix,  the,  185 

Ureteral  grafting,  520 
Ureter,  fistulas  of,  518 


534 


INDEX 


Ureter,  causes  of  fistulas  of,  518 
prophylactic  treatment  of,  519 
curative  treatment  of,  519 
plastic  occlusion,  519 
ureteral  grafting,  520 
Ureters,  vaginal  examination  of,  478 

fistulas  with  destruction  of  the  urethra, 

515 

Ureters,  abdominal  palpation  of,  478 
examination  of,  478 
technic  of  catheterization  of,  479 
Urethra,  dilatation  of  the,  481 
examination  of,  472 
exploratory  catheterization  of,  474 
surgery  of,  481 
treatment  of  diseases  of,  487 
of  suburethral  abscess,  489 
of  urethrocele,  489 

prolapse    of    urethral    mucous    mem- 
brane, 489 
tumors  of,  489 
of  wounds  of,  487 
of  foreign  bodies  in,  487 
of  urethritis,  487 
Urethrectomy,  indications  for,  483 

technic  of,  483 
Urethritis,  489 
Urethrocele,  489 
Urethroscope,  474 
Urethrotomy,  indications  for  internal  and 

external,  483 

Urinary  apparatus;  method  of  interroga- 
tion   of    patient    suffering    from 
diseases  of,  471 
operations  on,  471 
fistulas,  498 
Urine,  examination  of,  472 

operation  for  incontinence  of,  484 
Uterine  arteries,  general  anatomy  of,  198 
indications  for  the  ligation  of  by  the 

vaginal  route,  201 
ligature  of,  by  the  vaginal  route,  198 

by  the  abdominal  route,  409 
operative  technic  of  ligation  of  by 

the  vaginal  route,  200 
cancer,  abdominal  hysterectomy  for, 

357 
treatment  of  at  time  of  accouchment, 

441 

in  early  pregnancy,  440 
and  pregnancy,  treatment  of,  440 
catheterization,  contraindications  to, 

30 

instruments  used  in,  29 
use  of  sounds  and  bougies  in,  29 
technic  of,  30 
cavity,     application     of     medicated 

bougies  and  caustics  to,  45 
length  of,  30 
curette,  63 

curettage,  operation  for,  61 
patient  in  position  for,  62 
deviation,  treatments  of,  457 
fibroids  in  pregnancy,  choice  of  opera- 
tion, 435,  436 
radical  treatment  of,  432 
pregnancy,  treatment  of,  434 
fibromata,  vaginal  hysterectomy  in,  263 


Uterine  arteries,  treatment  of,  423,  430 

surgical,  431 

flexions,  operations  for,  193 
inversion,  457 

reduction    of,    by    the    abdominal 

route,  412 
treatment  of,  218 
vaginal  hysterectomy  for,  270 
prolapse;    general    indications  in  the 

surgical  treatment  of,  450 
prophylactic    and    medical    treat- 
ment of,  448 

vaginal  hysterectomy  for,  266 
rupture,  hysterectomy  for,  376 
subinvolution,  use  of  electricity  in  the 

treatment  of,  87 
Uteroplasty,  228 
Uterosacral     ligaments,      intraabdominal 

shortening  of  the,  406 
shortening  of,  218 

Uterus,  abdominal  operations  for  displace- 
ments and  deviations  of,  393 
anatomy  of  the  supports  of,  444 
and  adnexa,  treatment  of  inflamma- 
tory lesions  of,  413 
treatment  of  neoplasms  of  the,  423 
anteflexionof,  congenital  and  acquired, 

453 

Bascule  of,  217 
catheterization  of,  29 
complications  arising    during    curret- 

tage  of,  65 
curettage  of,  apart  from  the  puerperal 

state,  70 
in  cancer,  71 
curretting  of,  60,  61 
as  a  curative  agent,  71 
for  puerperal  metritis,  416 
dilatation  of,  31 
drainage  of,  47 
exaggerated  mobility  of,  452 
exploratory  curettage  of,  70 
failure  in  curetting,  67 
fixation  of,  by  method  of  Duhrssen 

224 
folding  up  and  fixation  of  the  tube 

to  the  anterior  wall  of  the,  402 
hemorrhage  following  curettage  of,  66 
hysterectomy  for  prolapse  of,  375 
imperfect    introduction    of    catheter 

into,  40 

indications  for  the  curettage  of,  68 
in  the  puerperal  state,  68 
slow  dilatation  of,  36 
malignant  tumors,  436 
method  of  applying  caustics  to,  46 
method  of  introducing  catheter  into, 

40 

mobile  retrodeviation  of,  454 
perforation  of,  during  curettage,  66 
retrodeviation  of,  453 
retroflexion  of  the  gravid,  456 
slow  or  gradual  dilatation  of,  34 
sterility,  stricture  and  obliteration  of 
the  uterine  cavity  following  curet- 
tage of,  67 

technic  of  instrumental  dilatation  of, 
33 


INDEX 


535 


Uterus,  treatment  of  inoperable  cancers  of 

the  pregnant,  441 
polypoid  inversion  of,  458 
prolapse  of,  444 

Vagina,  absence  of,  without  complications, 

129 

atresia  of,  127 
constriction  of,   by  metallic  sutures, 

168 

incision  of  (colpotomy),  213 
indications  for  tamponing,  28 
malignant  tumors  of,  124 
Muller's  method  for  the  total  removal 

of,  171 

operation  for  imperforation  of,  133 
palliative     treatment     of     inoperable 

cancer  of,  125 
stenosis  of,  126 
stricture  and  atresia  of,  125 
surgery  of,  119 
tamponing  of,  28 
treatment  of  fibromyoma  of,  123 

of  foreign  bodies  in,  120 

of  hematoma  of,  120 

of  inflammatory  lesion  of,  121 

tumors  of,  123 
Vaginal  application  of  electrotherapeutics, 

76 
arteries,  operative  technic  of  ligature 

of,  by  the  vaginal  route,  200 
atresia,  127 

with  menstrual  retention,  127 
discharge,  4 
discharges,  causes  of,  4 

varieties  of,  4 

douches,  medicinal  agents  used  in,  26 
enterocele,  451 

treatment  of,  451 
examination,  10 
fornices,    position    of,    as    found    by 

vaginal  examinations,  10 
hysterectomy,  235 

hemorrhage  following,  252 

lesion  of  neighboring  organs  during, 
253 

wound  of  the  ureter  during,  253 

wounds  of  the  bladder  during,  254 

wounds  of  the  rectum  during,  254 

peritonitis  following,  255 

intestinal  occlusion  following,  255 

eschars  following,  255 

for  cancer,  261 

complication  of,  252 

Doyen's,  256 

Doyen's    anterior    hemisection    in, 
243 

for  fibroids  of  uterus,  433 

for  fibromata,  260 

in  inflammation  of  the  adnexa,  265 

for  juxta-uterine  tumors,  271 

postoperative  details  of,  250 

operative  difficulties  of,  251 

Segond's  operation,  257 

J.  L.  Faure's  procedure,  259 

operative  technic  of,  236 

Pean's,  256 

procedure  of  Quenu  and  Muller,  258 


Vaginal  hysterectomy  in  prolapse,  266 

for  prolapse  Fritsch's  procedure  for, 

267 

for  uterine  inversion,  270 
various  procedures,  256 
injections,  22 

technic  of,  24 
medication,  27 
pessaries,  54 

Vaginismus,  treatment  of,  115 
Vaginitis,  treatment  of,  121 
Vagino-abdominal  pessary,  54 
Varieties  of  uterine  dilators,  32 
Various  operations  on  the  cervix,  192 

procedures  for  anterior  colporrhaphy, 

166 

Veit's  procedure,  148 
Vertical    and    transverse    section   of  the 

pelvis,  100 
Vesical   mucous   membrane,   prolapse   of, 

497 

Vesico-vaginal  fistulas,  498 
operation  for,  501 
general  technic  of,  511 
special  procedures  applicable  to  large 

losses  of  substance,  511 
flap  splitting,  506 

general  technic  for  operation  for,  501 
simple  denudation,  503 
treatment  of  fistulas  situated  in  the 
neighborhood  of  the  cervix  uteri, 
509 

operation  in  several  stages,  509 
preoperative  treatment  of,  500 
prophylactic  treatment  of,  499 
Vesico-uterine  fistulas,  514 
Vestibule,  98 
Vibration,  89 
Vulva,  bulb  of,  99 
chancre  of,  111 
cutaneous  tumors  of  the,  112 
elements  of  anatomy  of,  98 
elephantiasis  of,  112 
epithelioma  of,  114 
erythema  of,  treatment  of,  102 
examination  of,  9 
hematoma  of  and  treatment,  101 
treatment  of  herpes  of,  102 
inspection  of,  9 
lupus  of,  111 
malignant  tumors  of,  114 
molluscum  of,  113 
nerves  of,  101 

and  lymphatics  of,  101 
operations  constricting  or  closing  the. 

107 

operations  for  excision  of,  110 
subcutaneous  tumors  of  the,  113 
surgery  of,  98 

treatment  of  contusions  of,  101 
erythrasma  of,  103 

of  inflammatory  lesions  of,  1C2 
inflamed  sebasceous 

cysts  and  furuncle,  102 
intertrigo  of,  102 
of  traumata,  101 

Vulvar  orifice,  operation  for  enlarging  the, 
107 


536 


INDEX 


Vulvar  pruritus,  treatment  of,  105 
Vulvo-vaginal    gland,    inflammation    and 
abscess  of,  104 

treatment  of,  104 
Vulvitis,  mucous,  treatment  of,  103 

sebaceous,  treatment  of,  103 
Vulvo-vaginal  glands,  99 

tissues,  division  of,  108 
Vulvo-vaginitis  of  infancy,  treatment  of, 
103 


Watson's  operation  for  complete  rupture 

of  the  perineum,  156 
Wertheim-Schauta's  operation  for  anterior 

colpotomy,  227 

Wolffer's  parasacral  perineotomy,  283 
Wounds  of  the  urethra,  489 
treatment  of,  487 

X-rays  in  electrotherapeutics,  80 
Zuekerhandl's  parasacral  perineotomy,  283 


Date  Due 


CAT.    NO.    23   233  PRINTED   IN    U.S.A. 


s 

£, 


WP660 
H333g 

1913 
Hartman,  Henri 

Gynecological  operations 


—5  r 

•V"  •"• 

5  a 

CJ>  3 


WP660 
H333g 

1913 
I^artman,  Henri 

Gynecological  operations 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


